Mechanisms of change in digital interventions for depression: A systematic review and meta-analysis of six mediator domains

BACKGROUND

While the efficacy of digital interventions for the treatment of depression is well established, comprehensive knowledge on how therapeutic changes come about is still limited. This systematic review aimed to provide an overview of research on change mechanisms in digital interventions for depression and meta-analytically evaluate indirect effects of potential mediators.

METHODS

The databases CENTRAL, Embase, MEDLINE, and PsycINFO were systematically searched for randomized controlled trials investigating mediators of digital interventions for adults with depression. Two reviewers independently screened studies for inclusion, assessed study quality and categorized potential mediators. Indirect effects were synthesized with a two-stage structural equation modeling approach (TSSEM).

RESULTS

Overall, 25 trials (8110 participants) investigating 84 potential mediators were identified, of which attentional (8 %), self-related (6 %), biophysiological (6 %), affective (5 %), socio-cultural (2 %) and motivational (1 %) variables were the scope of this study. TSSEM revealed significant mediation effects for combined self-related variables (ab = -0.098; 95 %-CI: [-0.150, -0.051]), combined biophysiological variables (ab = -0.073; 95 %-CI: [-0.119, -0.025]) and mindfulness (ab = -0.042; 95 %-CI: [-0.080, -0.015]). Meta-analytical evaluations of the other three domains were not feasible.

LIMITATIONS

Methodological shortcomings of the included studies, the considerable heterogeneity and the small number of investigated variables within domains limit the generalizability of the results.

CONCLUSION

The findings further the understanding of potential change mechanisms in digital interventions for depression and highlight recommendations for future process research, such as the consideration of temporal precedence and experimental manipulation of potential mediators, as well as the application of network approaches.

Effectiveness of behavioral activation and mindfulness in increasing reward sensitivity and reducing depressive symptoms - A randomized controlled trial

Reward insensitivity is a potential key mechanism regarding the maintenance of depression. However, there is a lack of research examining and comparing the effectiveness of different psychological interventions in modifying reward insensitivity. This four-arm randomized controlled trial (RCT) investigated a two-week online intervention. After screening for eligibility, a total of 336 participants were randomized, and 224 participated per-protocol. Participants were assigned to either a) behavioral activation, b) mindfulness and gratitude, c) a combination of both, or d) a waitlist control condition. They received videos and implemented daily exercises. Reward sensitivity and depressive symptoms served as primary outcomes. Behavioral activation and mindfulness significantly improved depressive symptoms and reward sensitivity. However, the effects of behavioral activation were not superior. The combination treatment versus the waiting group was insignificant regarding reward insensitivity. Explorative analyses revealed that all intervention groups reduced anhedonia substantially. Our findings imply that brief online interventions with behavioral activation and mindfulness-based approaches can impact reward insensitivity, while effects for a combination were less clear. Nonetheless, our results do not allow us to infer the differential effectiveness of the interventions. There is a clear need for treatments better targeting maintaining factors of depression, such as reward insensitivity. Clinical trial registration number: NCT05402150.

An observational treatment study of metacognition in anxious-depression

Prior studies have found metacognitive biases are linked to a transdiagnostic dimension of anxious-depression, manifesting as reduced confidence in performance. However, previous work has been cross-sectional and so it is unclear if under-confidence is a trait-like marker of anxious-depression vulnerability, or if it resolves when anxious-depression improves. Data were collected as part of a large-scale transdiagnostic, four-week observational study of individuals initiating internet-based cognitive behavioural therapy (iCBT) or antidepressant medication. Self-reported clinical questionnaires and perceptual task performance were gathered to assess anxious-depression and metacognitive bias at baseline and 4-week follow-up. Primary analyses were conducted for individuals who received iCBT (n=649), with comparisons between smaller samples that received antidepressant medication (n=82) and a control group receiving no intervention (n=88). Prior to receiving treatment, anxious-depression severity was associated with under-confidence in performance in the iCBT arm, replicating previous work. From baseline to follow-up, levels of anxious-depression were significantly reduced, and this was accompanied by a significant increase in metacognitive confidence in the iCBT arm (β=0.17, SE=0.02, p<0.001). These changes were correlated (r(647)=-0.12, p=0.002); those with the greatest reductions in anxious-depression levels had the largest increase in confidence. While the three-way interaction effect of group and time on confidence was not significant (F(2, 1632)=0.60, p=0.550), confidence increased in the antidepressant group (β=0.31, SE = 0.08, p<0.001), but not among controls (β=0.11, SE = 0.07, p=0.103). Metacognitive biases in anxious-depression are state-dependent; when symptoms improve with treatment, so does confidence in performance. Our results suggest this is not specific to the type of intervention.

Effectiveness of online cognitive behavioural therapy on quality of life in adults with depression: A systematic review

WHAT IS KNOWN ON THE SUBJECT

Depression is a leading cause of disability worldwide that negatively impacts quality of life. Talk therapy such as cognitive behavioural therapy is an effective treatment for depression. The Internet is an important tool for mental healthcare delivery. Internet-delivered or online talk therapy interventions are associated with lower costs and improved accessibility. Current reviews do not address the effectiveness of Internet-delivered cognitive behavioural therapy (iCBT) on quality of life (QoL).

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Interventions for iCBT have better QoL improvements for individuals with greater depressive symptom severity, females, young adults and individuals with complex comorbid disorders. Support from a healthcare provider for iCBT interventions have better outcomes than self-guided therapy interventions. Tailoring the iCBT intervention to the specialized needs of the population is beneficial.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

There is potential to address treatment gaps for managing the care of individuals with depression. Utilizing iCBT promotes the integration of accessible mental healthcare in clinical settings. Healthcare providers can have a more comprehensive approach to delivering iCBT by considering adaptations relevant to the clinical population being treated.

ABSTRACT

INTRODUCTION: Major depressive disorder (MDD) is a leading cause of disability resulting from social, psychological and biological factors affecting quality of life (QoL). Cognitive behavioural therapy (CBT) is an effective psychotherapy for MDD. Internet-delivered CBT (iCBT) is associated with lower costs and improved accessibility.

AIM

We aimed to examine the effectiveness of iCBT on QoL in adults with depression.

METHOD

PubMed, Embase and PsycINFO were searched between 2010 and 2022. Inclusion criteria were experimental designs, adults ≥18 years old, depression diagnosis or valid self-report measure, iCBT intervention; and QoL outcome. Exclusion criteria were studies without depression analysis and intellectual disabilities or psychosis.

RESULTS

Seventeen articles were included, with a negative correlation between depression severity and QoL. Sex, age and physical comorbidity positively influenced effectiveness. Depressive severity, dysfunctional attitude and negative thinking were predictors and moderators of QoL. Clinician support can impact social interactions and sense of belonging.

DISCUSSION

Internet-delivered cognitive behavioural therapy is effective for improving QoL in adults with MDD. Severe depression, females, younger age and comorbid disorders were associated with greater QoL improvements.

IMPLICATIONS FOR PRACTICE

The findings suggest iCBT could address depression treatment gaps related to improving QoL. Utilizing iCBT potentially improves the care continuum for individuals with complex disorders.

Are self-managed online interventions for depression effective in improving behavioral activation? A secondary analysis of a cluster-randomized controlled trial

BACKGROUND

Online interventions can effectively improve depressive symptoms. They often include behavioral activation (BA) techniques, but research on the effects on behavioral activation is scarce. This study aims to examine short- and long-term effects of online interventions on behavioral activation in routine care.

METHODS

This study is a secondary analysis of a pragmatic cluster-randomized controlled trial (@ktiv) with a sample of N = 647 GP patients with mild to moderate depression. The intervention group (IG) received treatment-as-usual (TAU) and adjunct access to an online intervention; the control group (CG) received TAU. BA was assessed in terms of the frequency and enjoyment of pleasant activities at baseline, after six weeks and after six months. Intention-to-treat analyses were performed via multilevel mixed linear regression.

RESULTS

The frequency of pleasant activities was significantly higher in the IG than in the CG six months after baseline (t(1406) = 2.25, p = .024). The enjoyment of pleasant activities was significantly higher in the IG than in the CG both six weeks (t(1405) = 2.11, p = .035) and six months after baseline (t(1405) = 3.44, p = .001). Initial depressive symptoms significantly moderated the treatment effect on the enjoyment but not the frequency of pleasant activities.

LIMITATIONS

BA measures have not been validated in a clinical context.

CONCLUSIONS

GP patients with mild to moderate depressive symptoms profited from access to an online adjunct intervention in terms of improved behavioral activation. The findings emphasize the usefulness of online interventions as supportive options in mental health care.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.

Clients' and therapists' experiences of five general change mechanisms during an Internet-based cognitive behavioral intervention for family caregivers

OBJECTIVES

Despite its efficacy, little is known about what makes Internet-based cognitive behavioral therapy (iCBT) effective. We, therefore, analyze participants' and therapists' experiences of Grawe's five general change mechanisms (alliance, resource activation, clarification, problem actuation, mastery) during an iCBT intervention for family dementia caregivers, and how their experiences were related to treatment outcomes.

METHOD

Participants (N = 30) exchanged eight weekly messages with a therapist via an Internet platform. We used the Bern Post Session Report to assess participants' and therapists' experiences of the general change mechanisms after each session.

RESULTS

Treatment outcomes were associated with therapists' overall experiences of alliance, clarification, and mastery. Participants experienced more problem actuation than therapists. Only participants' and therapists' experiences of clarification over time differed.

CONCLUSIONS

Grawe's general change mechanisms are also relevant for iCBT. We recommend considering Grawe's framework when designing Internet-based therapeutic interventions and when training therapists to deliver such interventions.

Are Changes in Beliefs About Rumination and in Emotion Regulation Skills Mediators of the Effects of Internet-Delivered Cognitive-Behavioral Therapy for Depression and Anxiety? Results from a Randomized Controlled Trial

Background

Internet-delivered cognitive behavior therapy (iCBT) is effective in treating anxiety and depression. Research on how these interventions operate is scarce. This study explored whether emotion regulation skills and positive beliefs about rumination were affected by iCBT and if these constructs mediated changes in depression and anxiety.

Methods

This is a secondary analysis of a pragmatic randomized waitlist-controlled trial testing the effectiveness of supported iCBT. Adults with at least mild symptoms of depression or anxiety were included. Depression (PHQ-9), anxiety (GAD-7), positive beliefs about rumination (PBRS-A) and two emotion regulation skills: cognitive reappraisal (ERQ-A) and expressive suppression (ERQ-S), were measured at baseline and 8-weeks post-treatment.

Results

The analyses included 358 participants, 71% were female. Median age was 29. Linear mixed models showed statistically significant differences along ERQ-A in favor of the iCBT group (b = 1.83, SE = 0.82, p = .026). Mediation analyses showed reductions in depression (b = 0.31, SE = 0.15, p = 0.043) and anxiety symptoms (b = 0.27, SE = 0.14, p = 0.057) were partially mediated by gains in ERQ-A. No effects were observed for PBRS-A and ERQ-S.

Conclusions

These results align with findings from face-to-face therapy and add to the scarce literature on mediators of effects of iCBT, contributing to the understanding of how these interventions operate. Since mediator and outcome variables were measured at the same time, partial mediation results should be interpreted with caution since the study design did not account for temporality and therefore causality effects cannot be confirmed.

Trial Registration

ISRCTN91967124.

Following up internet-delivered cognitive behaviour therapy (CBT): A longitudinal qualitative investigation of clients' usage of CBT skills

BACKGROUND

While the acquisition and application of Cognitive Behaviour Therapy (CBT) skills is a core component and likely mechanism of effect maintenance in all CBT-based treatments, the extent of post-therapeutic CBT skills usage among internet-delivered CBT (iCBT) clients remains under-researched.

METHOD

Nested within a pragmatic randomized controlled trial, 241 participants received an 8-week supported iCBT intervention for anxiety and/or depression and answered open-ended questions about their use and experience of CBT skills at 3-, 6-, 9-, and 12-month follow-up. Recurrent, cross-sectional qualitative analysis following the descriptive and interpretive approach was used to create a taxonomy, through which all qualitative data was coded.

RESULTS

In total, 479 qualitative responses across 181 participants were analysed. Participants reported using a wide range of CBT skills and associated helpful and hindering experiences and impacts. The reasons for discontinued CBT skills usage were diverse, ranging from rare adverse effects to healthy adaptation.

CONCLUSION

The study shows how clients receiving iCBT in routine care learn CBT skills during treatment and utilize them in productive ways post-treatment. Findings coincide with similar research in face-to-face CBT and may inform future research to drive innovation and iCBT intervention development.

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.

Mobile App Use for Insomnia Self-Management in Urban Community-Dwelling Older Korean Adults: Retrospective Intervention Study

Background

As an evidence-based psychotherapy for treating insomnia, cognitive behavioral therapy for insomnia (CBT-I), which helps people with sleep problems to change their unhelpful sleep-related beliefs and habits, has been well-established in older adults. Recently, the utilization of mobile CBT-I apps has been getting attention from mental health professionals and researchers; however, whether mobile CBT-I apps are usable among older users has yet to be determined.

Objective

The aims of this study were to explore the relationships between subjective sleep quality and subjective memory complaints and depressive symptoms; to explore the relationship between perceived difficulty in mobile app use and usability of the mobile phone–based self-help CBT-I app, named MIND MORE, in urban community-dwelling Korean older adults; to compare changes in subjective sleep quality from pre-intervention to post-intervention, during which they used the mobile app over a 1-week intervention period; and evaluate adherence to the app.

Methods

During the 2-hour training program delivered on 1 day titled “Overcoming insomnia without medication: How to use the ‘MIND MORE’ mobile app for systematic self-management of insomnia” (pre-intervention), 41 attendants were asked to gain hands-on experience with the app facilitated by therapists and volunteer workers. They were then asked to complete questionnaires on sociodemographic characteristics, subjective evaluation of mental health status (ie, depression, memory loss and impairment, and sleep problems), and app usability. For the 1-week home-based self-help CBT-I using the app (post-intervention), 9 of the 41 program attendants, who had already signed up for the pre-intervention, were guided to complete the given questionnaires on subjective evaluation of sleep quality after the 1-week intervention, specifically 8 days after the training program ended.

Results

Due to missing data, 40 of 41 attendants were included in the data analysis. The main findings of this study were as follows. First, poor subjective sleep quality was associated with higher ratings of depressive symptoms (40/40; ρ=.60, P<.001) and memory complaints (40/40; ρ=.46, P=.003) at baseline. Second, significant improvements in subjective sleep quality from pre-intervention to post-intervention were observed in the older adults who used the MIND MORE app only for the 1-week intervention period (9/9; t₈=3.74, P=.006). Third, apart from the program attendants who did not have a smartphone (2/40) or withdrew from their MIND MORE membership (3/40), those who attended the 1-day sleep education program adhered to the app from at least 2 weeks (13/35, 37%) to 8 weeks (2/35, 6%) without any further contact.

Conclusions

This study provides empirical evidence that the newly developed MIND MORE app not only is usable among older users but also could improve subjective sleep quality after a 1-week self-help intervention period.

Intervention components, mediators, and mechanisms of change of Internet- and mobile-based interventions for post-traumatic stress disorder: protocol for a systematic review and meta-analysis

BACKGROUND

While Internet- and mobile-based interventions (IMIs) might possess the potential to increase access to evidence-based therapies for post-traumatic stress disorder (PTSD), comprehensive knowledge on active intervention components and change mechanisms underlying their efficacy is largely pending so far. The proposed systematic review and meta-analysis will systematically review the current status of research on the efficacy of IMIs for adult PTSD compared to active control conditions and identify active intervention components and mediators responsible for therapeutic change.

METHODS

A systematic literature search (PsycINFO, Medline/PubMed, Embase, CENTRAL, ICTRP, and Web of Science) will be conducted using keywords targeting "PTSD" and "Internet- and mobile-based interventions". Two independent researchers will retrieve studies eligible for inclusion and extract and evaluate data (design, population, outcomes, sample size, duration of intervention and follow-up, drop-out rate). Risk of bias will be assessed, and results will be synthesized qualitatively and evaluated meta-analytically when possible.

DISCUSSION

The results of this systematic review and meta-analysis might further contribute to the development of IMIs for PTSD by highlighting intervention components and mediators associated with their efficacy. Knowledge about the active ingredients might ultimately lead to more effective interventions and treatment packages, with implications for clinical practice and dissemination of these rather novel interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42019130314).

Patient experience of supported computerized CBT in an inner-city IAPT service: a qualitative study

Computerized cognitive behavioural therapy (cCBT) has been developed to address economic and clinical issues around limited access to evidence-based therapy. Supported cCBT (variously termed iCBT or eCBT) has been developed to address issues with the effectiveness of, and engagement with, cCBT. There has been no in-depth qualitative exploration of the patient experience of eCBT within the UK, which might aid improving its effectiveness. The aim of this study was to explore patient experience of eCBT in one inner-city National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) service using a semi-structured interview and Thematic Analysis methodology. Ten patients took part. Six main themes were identified: (1) Being Offered eCBT; (2) How eCBT Compares with Self-help; (3) The Patient's State of Mind; (4) The Relationship with the Supporter; (5) Preferring to Talk; (6) eCBT's Value as a Treatment. Participants in this study indicated a preference for face-to-face talking therapy, but were clear that they could form a therapeutic relationship via asynchronous messaging. They reported clinical benefit from the eCBT programme and online relationship, and acknowledged that accessing this immediately was valuable. Issues around the process of selecting patients for eCBT, including with regard to acknowledging or mitigating any negative emotional effects of eCBT, and how to offer and support users with it, are discussed.

Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications

Mental disorders are highly prevalent and often remain untreated. Many limitations of conventional face-to-face psychological interventions could potentially be overcome through Internet-based and mobile-based interventions (IMIs). This chapter introduces core features of IMIs, describes areas of application, presents evidence on the efficacy of IMIs as well as potential effect mechanisms, and delineates how Artificial Intelligence combined with IMIs may improve current practices in the prevention and treatment of mental disorders in adults. Meta-analyses of randomized controlled trials clearly show that therapist-guided IMIs can be highly effective for a broad range of mental health problems. Whether the effects of unguided IMIs are also clinically relevant, particularly under routine care conditions, is less clear. First studies on IMIs for the prevention of mental disorders have shown promising results. Despite limitations and challenges, IMIs are increasingly implemented into routine care worldwide. IMIs are also well suited for applications of Artificial Intelligence and Machine Learning, which provides ample opportunities to improve the identification and treatment of mental disorders. Together with methodological innovations, these approaches may also deepen our understanding of how psychological interventions work, and why. Ethical and professional restraints as well as potential contraindications of IMIs, however, should also be considered. In sum, IMIs have a high potential for improving the prevention and treatment of mental health disorders across various indications, settings, and populations. Therefore, implementing IMIs into routine care as both adjunct and alternative to face-to-face treatment is highly desirable. Technological advancements may further enhance the variability and flexibility of IMIs, and thus even further increase their impact in people's lives in the future.

Giving G a Meaning: An Application of the Bifactor-(S-1) Approach to Realize a More Symptom-Oriented Modeling of the Beck Depression Inventory–II

The Beck Depression Inventory–II is one of the most frequently used scales to assess depressive burden. Despite many psychometric evaluations, its factor structure is still a topic of debate. An increasing number of articles using fully symmetrical bifactor models have been published recently. However, they all produce anomalous results, which lead to psychometric and interpretational difficulties. To avoid anomalous results, the bifactor-(S-1) approach has recently been proposed as alternative for fitting bifactor structures. The current article compares the applicability of fully symmetrical bifactor models and symptom-oriented bifactor-(S-1) and first-order confirmatory factor analysis models in a large clinical sample ( N = 3,279) of adults. The results suggest that bifactor-(S-1) models are preferable when bifactor structures are of interest, since they reduce problematic results observed in fully symmetrical bifactor models and give the G factor an unambiguous meaning. Otherwise, symptom-oriented first-order confirmatory factor analysis models present a reasonable alternative.

Behavioral activation: Is it the expectation or achievement, of mastery or pleasure that contributes to improvement in depression?

BACKGROUND

Behavioral activation (BA) is receiving renewed interest as a stand-alone or as a component of cognitive-behavior therapy (CBT) for depression. However, few studies have examined which aspects of BA are most contributory to its efficacy.

METHODS

This is a secondary analysis of a 9-week randomized controlled trial of smartphone CBT for patients with major depression. Depression severity was measured at baseline and at end of treatment by the Patient Health Questionnaire-9. All aspects of behavioral activation tasks that the participants had engaged in, including their expected mastery and pleasure and obtained mastery and pleasure, were recorded in the web server. We examined their contribution to improvement in depression as simple correlations and in stepwise multivariable linear regression.

RESULTS

Among the 78 patients who completed at least one behavioral experiment, all aspects of expected or achieved mastery or pleasure correlated with change in depression severity. Discrepancy between the expectation and achievement, representing unexpected gain in mastery or pleasure, was not correlated. In stepwise regression, expected mastery and pleasure, especially the maximum level of the latter, emerged as the strongest contributing factors.

LIMITATIONS

The study is observational and cannot deduce cause-effect relationships.

CONCLUSIONS

It may be the expected and continued sense of pleasure in planning activities that are most meaningful and rewarding to individuals, and not the simple level or amount of obtained pleasure, that contributes to the efficacy of BA.

Internet- and Mobile-Based Psychological Interventions: Applications, Efficacy, and Potential for Improving Mental Health

Abstract. The majority of mental health disorders remain untreated. Many limitations of traditional psychological interventions such as limited availability of evidence-based interventions and clinicians could potentially be overcome by providing Internet- and mobile-based psychological interventions (IMIs). This paper is a report of the Taskforce E-Health of the European Federation of Psychologists’ Association and will provide an introduction to the subject, discusses areas of application, and reviews the current evidence regarding the efficacy of IMIs for the prevention and treatment of mental disorders. Meta-analyses based on randomized trials clearly indicate that therapist-guided stand-alone IMIs can result in meaningful benefits for a range of indications including, for example, depression, anxiety, insomnia, or posttraumatic stress disorders. The clinical significance of results of purely self-guided interventions is for many disorders less clear, especially with regard to effects under routine care conditions. Studies on the prevention of mental health disorders (MHD) are promising. Blended concepts, combining traditional face-to-face approaches with Internet- and mobile-based elements might have the potential of increasing the effects of psychological interventions on the one hand or to reduce costs of mental health treatments on the other hand. We also discuss mechanisms of change and the role of the therapist in such approaches, contraindications, potential limitations, and risk involved with IMIs, briefly review the status of the implementation into routine health care across Europe, and discuss confidentiality as well as ethical aspects that need to be taken into account, when implementing IMIs. Internet- and mobile-based psychological interventions have high potential for improving mental health and should be implemented more widely in routine care.

Digital IAPT: the effectiveness & cost-effectiveness of internet-delivered interventions for depression and anxiety disorders in the Improving Access to Psychological Therapies programme: study protocol for a randomised control trial

BACKGROUND

Depression and anxiety are common mental health disorders worldwide. The UK's Improving Access to Psychological Therapies (IAPT) programme is part of the National Health Service (NHS) designed to provide a stepped care approach to treating people with anxiety and depressive disorders. Cognitive Behavioural Therapy (CBT) is widely used, with computerised and internet-delivered cognitive behavioural therapy (cCBT and iCBT, respectively) being a suitable IAPT approved treatment alternative for step 2, low- intensity treatment. iCBT has accumulated a large empirical base for treating depression and anxiety disorders. However, the cost-effectiveness and impact of these interventions in the longer-term is not routinely assessed by IAPT services. The current study aims to evaluate the clinical and cost-effectiveness of internet-delivered interventions for symptoms of depression and anxiety disorders in IAPT.

METHODS

The study is a parallel-groups, randomised controlled trial examining the effectiveness and cost-effectiveness of iCBT interventions for depression and anxiety disorders, against a waitlist control group. The iCBT treatments are of 8 weeks duration and will be supported by regular post-session feedback by Psychological Wellbeing Practitioners. Assessments will be conducted at baseline, during, and at the end of the 8-week treatment and at 3, 6, 9, and 12-month follow-up. A diagnostic interview will be employed at baseline and 3-month follow-up. Participants in the waitlist control group will complete measures at baseline and week 8, at which point they will receive access to the treatment. All adult users of the Berkshire NHS Trust IAPT Talking Therapies Step 2 services will be approached to participate and measured against set eligibility criteria. Primary outcome measures will assess anxiety and depressive symptoms using the GAD-7 and PHQ-9, respectively. Secondary outcome measures will allow for the evaluation of long-term outcomes, mediators and moderators of outcome, and cost-effectiveness of treatment. Analysis will be conducted on a per protocol and intention-to-treat basis.

DISCUSSION

This study seeks to evaluate the immediate and longer-term impact, as well as the cost effectiveness of internet-delivered interventions for depression and anxiety. This study will contribute to the already established literature on internet-delivered interventions worldwide. The study has the potential to show how iCBT can enhance service provision, and the findings will likely be generalisable to other health services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN ISRCTN91967124. DOI: https://doi.org/10.1186/ISRCTN91967124 . Web: http://www.isrctn.com/ISRCTN91967124 . Clinicaltrials.gov : NCT03188575. Trial registration date: June 8, 2017 (prospectively registered).

Internetbasierte Therapie in der Versorgung von Patienten mit depressiven Störungen: Ein Überblick

Zusammenfassung. Internet- und mobilbasierten Interventionen wird großes Potenzial in der Behandlung von Menschen mit depressiver Symptomatik zugeschrieben. Diese Einschätzung hat sich in den letzten Jahren vor dem Hintergrund mehrerer Programmentwicklungen und einer Vielzahl von Studien zur Wirksamkeitsprüfung der zumeist auf der kognitiven Verhaltenstherapie basierten Angebote etabliert. Ziel der vorliegenden Übersichtsarbeit ist es, zu prüfen, inwieweit sich aus der empirischen Befundlage wissenschaftlich fundierte Empfehlungen für die Versorgungsbereiche Prävention, Primärversorgung, ambulante Psychotherapie, fachärztliche Versorgung sowie die stationäre Behandlung ableiten lassen. Hierfür werden die Ergebnisse ausgewählter Studien, die in den genannten Versorgungsbereichen angesiedelt sind und die Erhebung der Diagnose depressive Störung auf ein Expertenurteil stützen, kritisch bewertet. In der Schlussfolgerung ermöglicht die gegenwärtige Studienlage keine eindeutige Empfehlung zum Einsatz von internetbasierten Behandlungsprogrammen in den genannten Versorgungsbereichen.

Dropping out of a transdiagnostic online intervention: A qualitative analysis of client's experiences

INTRODUCTION

An important concern in Internet-based treatments (IBTs) for emotional disorders is the high dropout rate from these protocols. Although dropout rates are usually reported in research studies, very few studies qualitatively explore the experiences of patients who drop out of IBTs. Examining the experiences of these clients may help to find ways to tackle this problem.

METHOD

A Consensual Qualitative Research study was applied in 10 intentionally-selected patients who dropped out of a transdiagnostic IBT.

RESULTS

22 categories were identified within 6 domains. Among the clients an undeniable pattern arose regarding the insufficient support due to the absence of a therapist and the lack of specificity of the contents to their own problems.

CONCLUSIONS

The analyzed content has direct impact on the clinical application of IBTs. A more tailored manage of expectations as well as strategies to enhance the therapeutic relationship in certain clients are identified as the two key elements in order to improve the dropout in IBTs. Going further, in the mid and long run, ideographic interventions would be vital. The present study permits to better grasp the phenomenon of dropout in IBTs and delineate specific implications both in terms of research, training and practice.

Reducing depressive symptomatology with a smartphone app: study protocol for a randomized, placebo-controlled trial

BACKGROUND

Depression has become one of the leading contributors to the global disease burden. Evidence-based treatments for depression are available, but access to them is still limited in some instances. As technology has become more integrated into mental health care, computerized cognitive behavioral therapy (CBT) protocols have become available and have been recently transposed to mobile environments (e.g., smartphones) in the form of "apps." Preliminary research on some depression apps has shown promising results in reducing subthreshold or mild to moderate depressive symptoms. However, this small number of studies reports a low statistical power and they have not yet been replicated. Moreover, none of them included an active placebo comparison group. This is problematic, as a "digital placebo effect" may explain some of the positive effects documented until now. The aim of this study is to test a newly developed mobile app firmly grounded in the CBT theory of depression to determine whether this app is clinically useful in decreasing moderate depressive symptoms when compared with an active placebo. Additionally, we are interested in the app's effect on emotional wellbeing and depressogenic cognitions.

METHODS/DESIGN

Romanian-speaking adults (18 years and older) with access to a computer and the Internet and owning a smartphone are included in the study. A randomized, three-arm clinical trial is being conducted (i.e., active intervention, placebo intervention and delayed intervention). Two hundred and twenty participants with moderate depressive symptoms (i.e., obtaining scores >9 and ≤16 on the Patient Health Questionnaire, PHQ-9) will be randomized to the three conditions. Participants undergoing therapy, presenting serious mental health problems, or legal or health issues that would prevent them from using the app, as well as participants reporting suicidal ideation are excluded. Participants randomized to the active and placebo interventions will use the smartphone app for 6 weeks. A short therapist check-in via phone will take place every week. Participants in the delayed-intervention condition will be given access to the app after 6 weeks from randomization. The primary outcome is the level of depressive symptomatology. The intervention delivered through the app to the active condition includes psychoeducational materials and exercises based on CBT for depression, while the placebo intervention uses a sham version of the app (i.e., similar structure of courses and exercises).

DISCUSSION

To our knowledge, this study protocol is the first to test the efficacy of a smartphone app for depressive symptomatology in the form of a randomized controlled trial (RCT) that includes an active placebo condition. As such, this can substantially add to the body of evidence supporting the use of apps designed to decrease depression.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT03060200 . Registered on 1 February 2017. The first participant was enrolled on 17 February 2017.