[All in the mix? Blended psychotherapy as an example of digitalization in psychotherapy]

[Digital Interventions in Psychotherapy]

During the last 20 years, many digital interventions in psychotherapy have been developed and tested for a wide range of clinical problems. Digital interventions expand the range of treatment options and reach people who are unable or unwilling to take part in traditional psychotherapy. This article sheds light on various forms of digital interventions, such as unguided and guided self-help interventions, blended treatments, and video-based therapy, the practical use of Digital Health Applications (DiGA) in Germany, and the current state of research in digital interventions.

[Blended care: state of research and possibilities for implementation]

BACKGROUND

Psychotherapy is effective in treating mental disorders; however, not all patients benefit to the same extent and treatment gains are not always maintained. Blended care (BC) has the potential to improve psychotherapeutic care by combining traditional psychotherapy with online contents.

OBJECTIVE

To explore the potential of BC for psychotherapeutic care and investigate its implementation possibilities.

MATERIAL AND METHODS

Presentation of the effectiveness of various BC modalities, attitudes of users and decision-makers, and discussion of recommendations for its implementation.

RESULTS

Indications for the effectiveness of BC in different modalities has been shown in several studies. Both therapists and patients prefer BC over a purely online intervention and want customizable contents; however, it remains unclear for which patients BC is a particularly suitable treatment option.

CONCLUSION

Various combinations of BC have the potential to be an effective and financially viable treatment option. Successful implementation requires better education about BC and the provision of the necessary infrastructure.

A qualitative interview study of patients' attitudes towards and intention to use digital interventions for depressive disorders on prescription

Background

Depressive disorders are an emerging public health topic. Due to their increasing prevalence, patients with depressive disorders suffer from the lack of therapeutic treatment. Digital health interventions may offer an opportunity to bridge waiting times, supplement, or even substitute in-person treatment. Among others, the Unified Theory of Acceptance and Use of Technology (UTAUT) explains that actual technology use is affected by users' behavioural intention. However, patients' perspectives on digital interventions are rarely discussed within the specific context of primary care provided by general practitioners (GP) and need further exploration.

Method

A qualitative study design with semi-structured interviews was used to explore DTx-acceptance of patients with mild or moderate depression (n = 17). The audio-recorded interviews were transcribed verbatim, coded, and thematically analysed by qualitative content analysis.

Results

Patients' performance expectancies reveal that DTx are not perceived as a substitute for face-to-face treatment. Effort expectancies include potential advantages and efforts concerning technical, motivational, and skill-based aspects. Moreover, we identified health status and experience with depressive disorders as other determinants and potential barriers to patients' DTx acceptance: Difficult stages of depression or long-time experience are perceived hurdles for DTx use. GPs' recommendations were just partly relevant for patients and varied according to patients' consultancy preferences. But still, GPs have a crucial role for access due to prescription. GPs' influence on patients' DTx acceptance varies between three situations: (1) pre-use for consultation, (2) pre-use for access and (3) during DTx-use. Further, GPs' guidance could be especially relevant for patients during DTx-use in routine care.

Discussion

The UTAUT-based exploration suggests that acceptance determinants should be considered independently and embedded in personal and situational aspects. DTx require a healthcare professional to prescribe or diagnose the disease, unlike other digital offerings. We identified prescription- and depression-related determinants, exceeding existing theoretical constructs. GPs' guidance can compensate for some barriers to DTx use e.g., by increasing commitment and motivational support to strengthen patients' acceptance.

Conclusion

We argue for a multidimensional integration of acceptance determinants for further development of health technology acceptance research. Future research should specify how DTx can be integrated into routine care to strengthen user acceptance.

Feasibility, Adherence, and Effectiveness of Blended Psychotherapy for Severe Mental Illnesses: Scoping Review

BACKGROUND

Blended psychotherapy (bPT) combines face-to-face psychotherapy with digital interventions to enhance the effectiveness of mental health treatment. The feasibility and effectiveness of bPT have been demonstrated for various mental health issues, although primarily for patients with higher levels of functioning.

OBJECTIVE

This scoping review aims to investigate the feasibility, adherence, and effectiveness of bPT for the treatment of patients with severe mental illnesses (SMIs).

METHODS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, we conducted searches in PubMed, MEDLINE, Embase, PsycINFO, and PsycArticles for studies published until March 23, 2023.

RESULTS

Out of 587 screened papers, we incorporated 25 studies encompassing 23 bPT interventions, involving a total of 2554 patients with SMI. The intervention formats and research designs exhibited significant variation. Our findings offer preliminary evidence supporting the feasibility of bPT for SMI, although there is limited research on adherence. Nevertheless, the summarized studies indicated promising attrition rates, spanning from 0% to 37%, implying a potential beneficial impact of bPT on adherence to SMI treatment. The quantity of evidence on the effects of bPT for SMI was limited and challenging to generalize. Among the 15 controlled trials, 4 concluded that bPT interventions were effective compared with controls. However, it is noteworthy that 2 of these studies used the same study population, and the control groups exhibited significant variations.

CONCLUSIONS

Overall, our review suggests that while bPT appears promising as a treatment method, further research is necessary to establish its effectiveness for SMI. We discuss considerations for clinical implementation, directions, and future research.

Blending an internet-based emotion regulation intervention with face-to-face psychotherapy: Findings from a pilot randomized controlled trial

Background

Transdiagnostic interventions targeting shared mechanisms may improve treatment of mental health disorders. One way of providing such interventions is through blended treatment. This study examined the addition of an internet-based emotion regulation intervention to face-to-face psychotherapy in an outpatient setting.

Methods

In a pilot randomized controlled trial, 70 patients with a range of diagnoses were assigned to an internet-based program targeting emotion regulation + treatment as usual (face-to-face psychotherapy; TAU) (n = 35) or TAU (n = 35). Assessments occurred at baseline, after six, and after 12 weeks and included measures of symptom severity, emotion regulation, and various intervention feasibility parameters.

Results

ITT-analyses revealed no significant group-by-time interaction for the primary and almost all secondary outcomes. Descriptively, between-group effect sizes were in favor of the intervention group for almost all outcomes. Sensitivity analysis with patients who completed a minimum of three modules of the internet-based program showed a significant group-by-time interaction for the Difficulties in Emotion Regulation Scale in favor of the intervention group. The internet-based intervention showed good satisfaction ratings, user experience and usability. Findings from therapist measures complemented patient measures.

Conclusion

Preliminary results show that an internet-based emotion regulation intervention added to psychotherapy may not reduce symptom severity compared to psychotherapy alone. The intervention was rated positively by patients and therapists regarding several parameters, but certain features still need to be improved. An RCT powered to detect small between-group effect-sizes is necessary to consolidate findings.

Does an Internet-Based Emotion Regulation Intervention Provide Added Value for Acute Psychiatric Inpatient Care? Protocol for a Randomized Controlled Pilot Trial

BACKGROUND

There is a lack of studies on internet-based interventions in inpatient settings. This is especially true for studies of internet-based interventions in acute psychiatric inpatient care. Internet-based interventions in this specific setting may provide benefits such as patient empowerment and overall improved treatment outcomes. However, there may also be specific barriers to their implementation that are unique due to the complexity of acute psychiatric inpatient care.

OBJECTIVE

The aim of this study is to examine the feasibility and preliminary evidence for effectiveness of a web-based emotion regulation intervention provided as an add-on to acute psychiatric inpatient care.

METHODS

The goal is to randomly allocate 60 patients with a range of different diagnoses in a 1:1 ratio to either treatment as usual (TAU), which consists of acute psychiatric inpatient treatment, or to the intervention group, which will receive TAU plus access to a web-based intervention that focuses on reduction of emotion regulation difficulties and improvement of emotion regulation skills. The primary outcome is symptom severity, assessed with the short form of the Brief Symptom Inventory at baseline, after 4 weeks, after 8 weeks, and at hospital discharge. Secondary outcomes include 2 emotion regulation parameters, intervention use, usability, patient satisfaction, and reasons for patient loss to follow-up.

RESULTS

Participant recruitment started in August 2021 and as of March 2023 was ongoing. First publication of study results is expected in 2024.

CONCLUSIONS

This study protocol describes a study that intends to examine a web-based emotion regulation intervention in acute psychiatric inpatient care. The study will provide information on the feasibility of the intervention and possible effects on symptom severity and emotion regulation. The results will provide new insights on blended treatment, in this case the combination of a web-based intervention and face-to-face psychiatric treatment, in an understudied patient group and setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04990674; https://clinicaltrials.gov/ct2/show/NCT04990674.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47656.

Evaluation of Two Web-Based Interventions (Res-Up! and REMOTION) in Routine Outpatient Psychotherapy (Therapy Online Plus-TOP): Protocol for a Randomized Controlled Trial

BACKGROUND

Only 11%-40% of those with a mental disorder in Germany receive treatment. In many cases, face-to-face psychotherapy is not available because of limited resources, such as an insufficient number of therapists in the area. New approaches to improve the German health care system are needed to counter chronification. Web-based interventions have been shown to be effective as stand-alone and add-on treatments to routine practice. Interventions designed for a wide range of mental disorders such as transdiagnostic interventions are needed to make treatment for mental disorders more accessible and thus shorten waiting times and mitigate the chronification of mental health problems. In general, interventions can be differentiated as having either a capitalization (CAP) focus-thus drawing on already existing strengths-or a compensation (COMP) focus-trying to compensate for deficits. Up to now, the effectiveness of transdiagnostic web-based interventions with either a CAP or a COMP focus has not yet been evaluated.

OBJECTIVE

This study is the first to examine the effectiveness of two transdiagnostic web-based interventions: (1) the activation of resilience and drawing on existing strengths (CAP: Res-Up!) and (2) the improvement of emotion regulation (COMP: REMOTION), compared with care as usual (CAU) in routine outpatient psychotherapy.

METHODS

Adults with at least 1 mental health disorder will be recruited at 4 outpatient centers in Germany. Participants will then be randomized equally into 1 of the 2 intervention groups Res-Up! (CAP) and REMOTION (COMP) or into the control group (CAU). Assessments will be made at baseline (T0), at 6 weeks after treatment start (T1), and at 12 weeks after treatment start (T2). A primary outcome will be symptom severity (Brief Symptom Inventory-18). Secondary outcomes will focus on emotion regulation and resilience.

RESULTS

Participant recruitment and data collection started in April 2020 and were ongoing as of July 2022. We expect participants to benefit more from the interventions than from the CAU control on the dimensions of symptom severity, resilience, and emotion regulation. Furthermore, we expect to find possible differences between CAP and COMP. The results of the study are expected in 2023.

CONCLUSIONS

This randomized controlled trial will compare CAU with the transdiagnostic web-based interventions Res-Up! and REMOTION, and will thus inform future studies concerning the effectiveness of transdiagnostic web-based interventions in routine outpatient psychotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04352010; https://clinicaltrials.gov/ct2/show/NCT04352010.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41413.

Increasing the effectiveness of psychotherapy in routine care through blended therapy with transdiagnostic online modules (PsyTOM): study protocol for a randomized controlled trial

BACKGROUND

In blended therapy, face-to-face psychotherapy and Internet-based interventions are combined. Blended therapy may be advantageous for patients and psychotherapists. However, most blended interventions focus on cognitive behavioral therapy or single disorders, making them less suitable for routine care settings.

METHODS

In a randomized controlled trial, we will compare blended therapy and face-to-face therapy in routine care. We intend to randomize 1152 patients nested in 231 psychotherapists in a 1:1 ratio. Patients in the blended therapy group will receive access to a therapeutic online intervention (TONI). TONI contains 12 transdiagnostic online modules suited for psychodynamic, cognitive behavioral, and systemic therapy. Psychotherapists decide which modules to assign and how to integrate TONI components into the psychotherapeutic process to tailor treatment to their patients' specific needs. We will assess patients at baseline, 6 weeks, 12 weeks, and 6 months. Patients enrolled early in the trial will also complete assessments at 12 months. The primary outcomes are depression and anxiety at 6-month post-randomization, as measured by PHQ-8 and GAD-7. The secondary outcomes include satisfaction with life, level of functioning, personality traits and functioning, eating pathology, sexual problems, alcohol/drug use, satisfaction with treatment, negative effects, and mental health care utilization. In addition, we will collect several potential moderators and mediators, including therapeutic alliance, agency, and self-efficacy. Psychotherapists will also report on changes in symptom severity and therapeutic alliance. Qualitative interviews with psychotherapists and patients will shed light on the barriers and benefits of the blended intervention. Furthermore, we will assess significant others of enrolled patients in a sub-study.

DISCUSSION

The integration of online modules which use a common therapeutic language and address therapeutic principles shared across therapeutic approaches into regular psychotherapy has the potential to improve the effectiveness of psychotherapy and transfer it into everyday life as well help save therapists' resources and close treatment gaps. A modular and transdiagnostic setup of the blended intervention also enables psychotherapists to tailor their treatment optimally to the needs of their patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00028536. Registered on 07.06.2022.

Das Beste aus zwei Welten: Eine systematische Übersicht zu Faktoren der Implementierung einer “Blended Therapy” (Gemischte Therapie) in der Psychotherapeutischen Routineversorgung

<b><i>Ziel:</i></b> Diese Arbeit gibt einen Überblick über bisherige wissenschaftliche Empfehlungen zur Implementierung der blended therapy, d.h. der Kombination von Therapien in Präsenz und via digitaler Medien. Die Empfehlungen um­fassen die Themen: (1) wahrgenommene Barrieren von Psychotherapeut*innen, (2) Format der blended therapy und (3) Indikationen für Patient*innen. In diesem Rahmen werden Faktoren aufgezeigt, die Akteur*innen im Gesundheitssystem als Orientierung dienen können, welche Determinanten bei der Implementierung in die Routineversorgung zu berücksichtigen sind. <b><i>Methodik:</i></b> Die systematische Suche erfolgte in den Datenbanken PsycArticles, PsycInfo, PSYNDEX und PubMed. <b><i>Ergebnisse:</i></b> Die Publikationen umfassen vier quantitative, neun qualitative sowie drei Mixed-Methods-Studien. Die bisherigen Arbeiten kommen zu dem Ergebnis, dass Psychotherapeut*innen frühzeitig in den Implementierungsprozess einbezogen und langfristige supportive Maßnahmen für die Umstrukturierung der bisherigen Arbeitsroutine geschaffen werden sollten. Das Format der blended therapy sollte nicht standardisiert angewandt, sondern vielmehr individuell an die Patient*innen angepasst werden. Hinsichtlich möglicher Indikationen werden verschiedene Einflussfaktoren der Patient*innen diskutiert, die bisher jedoch nur unzureichend untersucht wurden. <b><i>Diskussion:</i></b> Bisherige Studien weisen größtenteils homogene Charakteristika und Ergebnisse auf. Forschungslücken bestehen hinsichtlich der Frage, inwieweit sich die Ergebnisse auf andere Therapieschulen, Berufsgruppen und Störungsbilder übertragen lassen. <b><i>Schlussfolgerung:</i></b> Das Review veranschaulicht, dass es wichtiger Vorarbeit hinsichtlich der Anwendungsunterstützung für Psychotherapeut*innen sowie weiterer Forschungsaktivität bedarf, um die Implementierung von blended therapy im Sinne einer möglichen Verbesserung der psychotherapeutischen Versorgung voranzutreiben.