The effects of component-specific treatment compliance in individually tailored internet-based treatment

Who benefits from guided internet-based interventions? A systematic review of predictors and moderators of treatment outcome

To our knowledge, no systematic review has been conducted on predictors or moderators of treatment outcome across diagnoses in guided internet-based interventions (IBIs) for adults. To identify who benefits from this specific format and therein inform future research on improving patient-treatment fit, we aimed to aggregate results of relevant studies. 2100 articles, identified by searching the databases PsycInfo, Ovid Medline, and Pubmed and through snowballing, were screened in April/May 2021 and October 2022. Risk of bias and intra- and interrater reliability were assessed. Variables were grouped by predictor category, then synthesized using vote counting based on direction of effect. N = 60 articles were included in the review. Grouping resulted in 88 predictors/moderators, of which adherence, baseline symptoms, education, age, and gender were most frequently assessed. Better adherence, treatment credibility, and working alliance emerged as conclusive predictors/moderators for better outcome, whereas higher baseline scores predicted more reliable change but higher post-treatment symptoms. Results of all other predictors/moderators were inconclusive or lacked data. Our review highlights that it is currently difficult to predict, across diagnoses, who will benefit from guided IBIs. Further rigorous research is needed to identify predictors and moderators based on a sufficient number of studies. PROSPERO registration: CRD42021242305.

Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review

BACKGROUND

New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness.

OBJECTIVE

This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy.

METHODS

We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study.

RESULTS

This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability.

CONCLUSIONS

Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations.

Do I really have to do my homework? The role of homework compliance in cognitive behavioral therapy for irritable bowel syndrome

Treatment guidelines identify cognitive behavioral therapy (CBT) as a treatment of choice for irritable bowel syndrome (IBS). As a learning-based treatment, homework assignments are regarded as important for optimizing outcomes for CBT-treated patients. However, their actual benefit for IBS is unknown. This study examined whether homework completion corresponds with immediate and sustained treatment response in IBS patients enrolled in CBT treatment. Subjects were 358 IBS patients receiving clinic-based CBT (10 session), home-based CBT (4 session), or a 4 session, non-specific IBS education comparator as part of a large NIH trial. Homework completion was rated by clinician at each session. IBS symptom improvement was measured with the Clinician Global Improvement Scale at treatment week 5, post-treatment (week 12), and at follow-ups (weeks 22, 34, 46, 62). Homework completion rates over the 10-week acute phase corresponded with greater IBS symptom improvement and patient satisfaction at post-treatment. Early treatment homework completion did not predict early treatment response. Contrary to expectations, homework compliance rates were not greater among in-clinic session patients than home-based patients. Data lend empirical support to the clinical value of homework in teaching patients how to self-manage painful GI symptoms refractory to conventional medical and dietary therapies.

Utilization of healthcare and prescription medicines after non-pharmacological interventions for depression - A 3-year register follow-up of an RCT in primary care

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A 3-year register follow-up of an RCT for depression interventions was conducted.

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Healthcare utilization and dispensed medicines were used as register outcomes.

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The interventions had no effect on consultations for mental illness during follow-up.

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Both interventions are appropriate additions to mild-moderate depression care.

Depression is a common, recurrent disorder. There is a need for readily available treatments with few negative side effects, that demands little resources and that are effective both in the short- and long term.

Our aim was to investigate the long-term effectiveness of two different interventions; physical exercise and internet-based cognitive behavioural therapy (internet-CBT), compared to usual care in patients with mild to moderate depression in a Swedish primary care setting.

We performed a register-based 3-year follow-up study of participants in the randomized controlled trial REGASSA (n = 940) using healthcare utilization and dispensed medicines as outcomes.

We found no difference between the three groups regarding proportion of participants consulting healthcare due to mental illness or pain during follow-up. Regarding number of consultations, there was no difference between the groups, except for consultations related to pain. For this outcome both treatment arms had significantly fewer consultations compared to usual care, during year 2–3, the risk ratio (RR) for physical exercise and internet-CBT was 0.64 (95% CI = 0.43–0.95) and 0.61 (95% CI = 0.41–0.90), respectively.

A significantly lower proportion of patients in both treatment arms were dispensed hypnotics and sedatives year 2–3 compared to the usual care arm, RR for both physical exercise and internet-CBT was 0.72 (95% CI = 0.53–0.98). No other differences between the groups were found.

In conclusion, considering long-term effects, both physical exercise and internet-CBT, being resource-efficient treatments, could be considered as appropriate additions for patients with mild to moderate depression in primary care settings.

Trial registration: The original RCT was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).

Research on Mental Stress Recognition of Depressive Disorders in Patients With Androgenic Alopecia Based on Machine Learning and Fuzzy K-Means Clustering

Under the new trend of industry 4.0 software-defined network, the value of meta heuristic algorithm was explored in the recognition of depression in patients with androgenic alopecia (AGA), and there was an analysis on the effect of comprehensive psychological interventions in the rehabilitation of AGA patients. Based on the meta heuristic algorithm, the Filter and Wrapper algorithms were combined in this study to form a new feature selection algorithm FAW-FS. Then, the classification accuracy of FAW-FS and the ability to identify depression disorders were verified under different open data sets. 54 patients with AGA who went to the Medical Cosmetic Center of Tongji Hospital were selected as the research objects and rolled into a control group (routine psychological intervention) and an intervention group (routine + comprehensive psychological interventions) according to different psychological intervention methods, with 27 cases in each group. The differences of the self-rating anxiety scale (SAS), self-rating depression scale (SDS), Hamilton depression scale (HAMD), and physical, psychological, social, and substance function scores before and after intervention were compared between the two groups of AGA patients, and the depression efficacy and compliance of the two groups were analyzed after intervention. The results showed that the classification accuracy of FAW-FS algorithm was the highest in logistic regression (LR), decision tree (DT), K-nearest neighbor (KNN) algorithm, support vector machine (SVM) algorithm, and random forest (RF) algorithm, which was 80.87, 79.24, 80.42, 83.07, and 81.45%, respectively. The LR algorithm had the highest feature selection accuracy of 82.94%, and the classification accuracy of depression disorder in RF algorithm was up to 73.01%. Besides, the SDS, SAS, and HAMD scores of the intervention group were lower sharply than the scores of the control group (p < 0.05). The physical function, psychological function, social function, and substance function scores of the intervention group were higher markedly than those of the control group (p < 0.05). In addition, the proportions of cured, markedly effective, total effective, full compliance, and total compliance patients in the intervention group increased obviously in contrast to the proportions of the control group (p < 0.05). Therefore, it indicated that the FAW-FS algorithm established in this study had significant advantages in the recognition of depression in AGA patients, and comprehensive psychological intervention had a positive effect in the rehabilitation of depression in AGA patients.

Effects of patient-driven iCBT for anxiety in routine primary care and the relation between increased experience of empowerment and outcome: A randomized controlled trial

BACKGROUND

The World Health Organization has declared that primary care should be organized to empower individuals, families, and communities to optimize health. Internet cognitive behavioral therapy (iCBT) tailored by psychologists' initial assessments to meet patients' specific needs have shown promising effects. However, few studies have evaluated patient involvement in decisions during iCBT.

AIM

This study aimed to explore the effect of patient-driven iCBT compared to standard iCBT on perceived control over treatment, adherence, and level of anxiety symptoms. A secondary aim was to assess the relationship between changes in empowerment and changes in anxiety symptoms.

METHOD

Participants were patients recruited form primary care and assessed as meeting the criterion for an anxiety disorder. Participants were randomized to patient-driven iCBT (n = 27) or standard iCBT (n = 28). Patient-driven iCBT was adapted to participants' preferences regarding for example focus of treatment program and order of modules. Participants randomized to the control condition received the standard iCBT program for anxiety disorders at the participating unit. The outcome measures were patients' perceived control over treatment, adherence to treatment, symptoms of anxiety, depression and general disability as well as the experience of empowerment.

RESULTS

Participants in patient-driven iCBT had statistically higher perceived control over treatment (t(43) = 2.13, p = .04). Symptoms were significantly reduced in both arms with regards to anxiety, depression, and general disability. A significant time per condition interaction effect for anxiety symptoms was observed (df = 45.0; F = 3.055; p = .038), where the patient-driven condition had a significantly larger reduction in anxiety. For both groups a significant correlation of r = -0.47 was found between changes in empowerment and changes in anxiety.

CONCLUSION

Results indicate that iCBT that is patient-driven, may have a greater effect on anxiety, than standard iCBT. The effect on perceived control over treatment might also be larger in patient-driven treatments than in standard iCBT. Internet-based therapies inherently promote as active agents of their own care and might be well suited for promoting perceived control and empowerment. Findings need to be replicated given the small sample size and the explorative nature of the study.

CLINICAL TRIALS REGISTRATION

NCT04688567.

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.

Weekly Self-Ratings of Treatment Involvement and Their Relation to Symptom Reduction in Internet Cognitive Behavioral Therapy for Insomnia

Background

Treatment involvement, including involvement with written material as well as homework assignments, has previously been associated with better outcomes in cognitive behavioral therapy, but there is a lack of knowledge on which specific aspects of involvement that are the most promising for use as predictors of treatment effects.

Methods

The objective of this study was to use a battery of weekly self-rated questions regarding different aspects of participant involvement during 8 weeks of either guided internet cognitive behavioral therapy for insomnia (ICBT-i, n = 73), or an active internet-delivered control treatment also including homework (ICBT-ctrl, n = 75), to predict reductions in insomnia severity after treatment. The markers of involvement were single questions on amount of time spent on treatment, amount of text read, amount of subjective knowledge gained and index scores of homework quantity (based on ratings of how many times specific techniques were used) and homework quality (based on ratings of the understanding, used as intended, and helpfulness of each specific technique).

Results

While none of the markers predicted reductions in insomnia severity for participants in the ICBT-ctrl group, text read, subjective knowledge gain, and homework quality predicted larger reductions in insomnia severity for participants in ICBT-i. Amount of subjective knowledge gained was a particularly useful marker in the ICBT-i group, since weekly ratings from the first half of treatment sufficed to explain a rather large proportion of variance in insomnia severity post treatment (14%).

Conclusions

The results strengthen subjective knowledge gain as a candidate for use as a predictor of treatment effects in ICBT-i.

The Role of Homework Engagement, Homework-Related Therapist Behaviors, and Their Association with Depressive Symptoms in Telephone-Based CBT for Depression

Background

Telephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist. The study describes patient homework engagement (HE) and homework-related therapist behaviors (TBH) over the course of treatment and explores their relation to depressive symptoms during tel-CBT for patients with depression.

Methods

Audiotaped sessions (N = 197) from complete therapies of 22 patients (77% female, age: M = 54.1, SD = 18.8) were rated by five trained raters using two self-constructed rating scales measuring the extent of HE and TBH (scored: 0–4).

Results

Average scores across sessions were moderate to high in both HE (M = 2.71, SD = 0.74) and TBH (M = 2.1, SD = 0.73). Multilevel mixed models showed a slight decrease in HE and no significant decrease in TBH over the course of treatment. Higher TBH was related to higher HE and higher HE was related to lower symptom severity.

Conclusions

Results suggest that HE is a relevant therapeutic process element related to reduced depressive symptoms in tel-CBT and that TBH is positively associated with HE. Future research is needed to determine the causal direction of the association between HE and depressive symptoms and to investigate whether TBH moderates the relationship between HE and depressive symptoms.

Trial Registration

ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Individually tailored internet treatment in routine care: A feasibility study

INTRODUCTION

Disorder-specific internet treatment, based on cognitive-behavioral therapy, has been a part of routine psychiatric care in Sweden since 2007, provided at the Internet Psychiatry Clinic in Stockholm. Individually tailored treatments, with the opportunity to target more than one condition within the same treatment, has since then been evaluated in randomized trials with promising results. To introduce an individually tailored treatment into a clinical setting originally designed for disorder-specific processes creates challenges, such as how to choose the optimal treatment type for each patient.

METHODS

The feasibility of a proposed new routine for assessment and initiation of either a disorder-specific or an individually tailored treatment was tested on patients self-referring to the Internet Psychiatry Clinic during three weeks (N = 66), by exploring the match between comorbid problem areas and patients' preferred treatments with available disorder-specific treatment options, as well as presenting these patients' preferred problem areas to work with in individually tailored treatment, and evaluating any problems with the proposed routine. The feasibility (i.e. satisfaction, credibility, treatment activity, adherence, and preliminary symptom reductions) in the individually tailored treatment were also explored on a smaller subgroup of eight patients.

RESULTS

A majority (65%) of patients screened had at least 2 comorbid problem areas, although 25% of these comorbid patients that where allocated with the help of the proposed routine still initiated disorder-specific treatment. The proposed assessment routine functioned satisfactorily within the up and running internet clinic. The individually tailored treatment was promising regarding satisfaction, credibility, adherence, and preliminary reductions in symptoms. A notable challenge encountered was that the platform was not set up to assist with assessment process or outcome monitoring for individually tailored treatment.

CONCLUSIONS

It seems feasible to combine individually tailored internet treatment and disorder-specific internet treatment within the same internet clinic. The addition of tailored treatment may prove to increase the number of patients included in treatment.

The effects of component-specific treatment compliance in individually tailored internet-based treatment

The objective of this study was to explore the effects of treatment compliance in a guided individually tailored internet‐based treatment (TAIL) in relation to depression and co‐morbid symptoms. Compliance with the homework in the different treatment components in TAIL, each aimed at a specific condition, was rated for 207 participants by independent assessors. Six subgroups (n = 34–131) were constructed consisting of participants with co‐occurring symptoms of worry, panic, social anxiety, stress, insomnia, or pain. For each group, hierarchical regression was used to investigate whether the total sum of compliance points, Overall Compliance, predicted reductions in depression and in condition‐specific symptoms. Also, in each subgroup, it was tested whether working with specific treatment components, Specific Compliance, predicted reduction of the targeted symptoms. Overall Compliance predicted 15% of the reduction in depression symptoms. For participants with worry, panic, social anxiety, stress, or insomnia, Overall Compliance also predicted symptom reductions in that specific condition. Specific Compliance predicted reduction in the targeted symptoms for participants with social anxiety, stress, and insomnia. Specific Compliance with stress and insomnia components also predicted reductions in depression. Our results strengthen the importance of compliance in internet‐based treatments. Because compliance with stress and insomnia components was particularly important for broad symptom reductions, these conditions should not be ignored when treating patients with co‐morbid symptoms.