Internet-based Mental Health Services in Norway and Sweden: Characteristics and Consequences

Electronic Mental Health as an Option for Egyptian Psychiatry: Cross-Sectional Study

BACKGROUND

Egypt is a country of nearly 100 million citizens, and there are less than 1000 registered psychiatrists. The mental health care system is under resourced and nearly inaccessible for the majority of the population. In addition, youth under the age of 25 years represent 50% of Egyptian citizens; however, there are no specific services addressing their unique needs. How can the needs of the largest population in the Middle East be effectively addressed? Is a web-based framework an option for Egyptian psychiatrists to serve the population?

OBJECTIVE

The aims of this study were to better understand the opinions of psychiatrists on the current state of mental health care services in Egypt and their current knowledge on electronic mental health (EMH); assess the attitudes of Egyptian psychiatrists toward web-based interventions and telemedicine for mental health; and identify perceived advantages and barriers of EMH development in Egypt.

METHODS

A cross-sectional survey was conducted online among 640 Egyptian psychiatrists. It included a total of 36 items within a set of 16 questions asking about EMH literacy, integrating EMH into the mental health care system, and the perceived priorities and barriers of EMH. The sampling was supported by Tanta University, a large academic institution close to Cairo. Statistical analysis was performed using SPSS 25 (IBM Corp). Descriptive statistics, the chi-square test, the independent sample t test, and analysis of variance were applied.

RESULTS

A total of 188 participants responded (response rate of 29.4%), of which 54.2% (102/188) were female and 54.3% (102/188) were between 30 and 45 years old. Less than half of the participants thought that the current health care system was efficient for adults (69/155, 44.4%), and even less thought it was efficient for youth (44/155, 28.3%). Almost all participants agreed that EMH would be beneficial for patient care (147/155, 94.8%) and that integrating EMH into the current health care system would be a good idea (118/155, 76.2%). The highest rated utility of web-based solutions was documentation, followed by psychoeducation and communication with professionals. The main advantages were to improve access to care in rural areas of the country and its convenience.

CONCLUSIONS

There is scarcity of mental health resources in Egypt. Egyptian psychiatrists are interested in EMH and believe web-based platforms can become part of the solution for the Egyptian mental health care system.

Ethical Issues in Online Psychotherapy: A Narrative Review

BACKGROUND

The provision of psychotherapy over distance using technology is a growing market reaching many patients and therefore the risks and benefits need to be known by all psychotherapists whether they themselves practice online or not. This comprehensive review of the main ethical arguments for and against different forms of online psychotherapy aims to enhance discussion of ethical issues in this growing area.

METHODS

A search of three databases (PubMed, PsycINFO, Web of Science) was conducted in August 2019 using a specific search protocol yielding 249 publications.

RESULTS

Of 24 ethical arguments in favor of online psychotherapy and 32 against, the top five ethical arguments in favor of online psychotherapy were (1) increased access to psychotherapy and service availability and flexibility; (2) therapy benefits and enhanced communication; (3) advantages related to specific client characteristics (e.g. remote location); (4) convenience, satisfaction, acceptance, and increased demand; and (5) economic advantages. The top five ethical arguments against engagement in online psychotherapy were (1) privacy, confidentiality, and security issues; (2) therapist competence and need for special training; (3) communication issues specific to technology; (4) research gaps; and (5) emergency issues.

CONCLUSIONS

The findings may be of help to practitioners in deciding whether to engage in online psychotherapy, and in informing patients about risks and benefits, improving ethical guidelines, and stimulating further ethical discussion. The findings are argumentative and qualitative in nature, and further quantitative research is needed.

Physical Couple and Family Violence Among Clients Seeking Therapy: Identifiers and Predictors

Introduction

Couple violence (CV) affects many, and the consequences of those actions are grave, not only for the individual suffering at the hand of the perpetrator but also for the other persons in the family. Violence often happens among more than just the adults within one family. Even if CV has been thoroughly investigated in the general population very few studies have investigated this objective on a clinical sample, and none of these have included family violence.

Aim

This article identifies and describes the group of clients that have issues of physical couple and family violence. It analyses a model that can help to discover physical violence and help therapists to assess what actions to take in therapy to prevent further physical violence.

Methodology

Descriptive analysis, t-tests, and structural equation modeling (SEM) are used on a sample of clients receiving couple and family therapy (CFT) in Norway (N = 830). Family violence is modeled by the partner’s expectations toward each other, levels of anger, sexual satisfaction, and self-control.

Results

One-in-five clients experienced physical CV in their current relationship and one-in-four experienced physical family violence. The group of clients who experienced CV differed from those without such experiences in having lower income, more prior experience with psychotherapy, more experience with alcohol abuse in childhood, and far more physical family violence in their current family. Our model predicting physical couple and family violence explained as much as 53% of family violence and had three positive, significant predictors (expectation, anger, and sexual satisfaction) and one, significant negative predictor (self-control). Somewhat unexpected, sexual satisfaction was a positive, and not a negative, predictor of violence.

Conclusion

Our study identified one-in-four clients in CFT experience physical CV. Unreasonable expectation from one partner toward the other, anger and sexual satisfaction were positive predictors of physical violence, while self-control was found to be a negative predictor of physical violence. Implications for therapeutic work and the prevention of physical violence are discussed.

A systematic review of technology-assisted interventions for co-morbid depression and substance use

Introduction

Mental health interventions disseminated via, or accessed using, digital technologies are an innovative new treatment modality for managing co-morbid depression and substance use disorder. The present systematic review assessed the current state of this literature.

Methods

A search of the Cochrane Library, Embase, Pubmed, PsycInfo and Scopus databases identified six eligible studies ( Nparticipants = 862), utilising quasi-experimental or randomised controlled designs. Reporting quality was evaluated and Hedges’ g effect sizes (with 95% confidence intervals and p-values) were calculated to determine treatment effectiveness. Process outcomes (e.g. treatment satisfaction, attrition rates) were also examined.

Results

Quality ratings demonstrated high internal validity, although external validity was low. Effect size data revealed medium to large and short-term improvements in severity of depression and substance use symptoms in addition to global improvement in social, occupational and psychological functioning. Longer-term treatment effectiveness could not be established, due to the limited available data. Preliminary findings suggest that there was high client satisfaction, therapeutic alliance and client engagement.

Discussion

Mobile phone devices and the Internet can help to increase access to care for those with mental health co-morbidity. Large-scale and longitudinal research is, however, needed before digital mental healthcare becomes standard practice. This includes establishing critical therapeutic factors including optimum levels of assistance from clinicians.

Social relationships among adolescents as described in an electronic diary: a mixed methods study

Social relationships among adolescents with mental disorders are demanding. Adolescents with depressive symptoms may have few relationships and have difficulties sharing their problems. Internet may offer reliable and easy to use tool to collect real-time information from adolescents. The aim of this study is to explore how adolescents describe their social relationships with an electronic diary. Mixed methods were used to obtain a broad picture of adolescents' social relationships with the data gathered from network maps and reflective texts written in an electronic diary. Adolescents who visited an outpatient clinic and used an intervention (N=70) designed for adolescents with signs of depression were invited to use the electronic diary; 29 did so. The quantitative data gathered in the electronic diary were summarized with descriptive statistics, and the qualitative data were categorized using a thematic analysis with an inductive approach. We found that social relationships among adolescents with signs of depression can vary greatly in regards to the number of existing relationships (from lacking to 21) and the quality of the relationships (from trustful to difficult). However, the relationships may change, and the adolescents are also willing to build up their social relationships. Professionals need to be aware of the diversity of adolescents' social relationships and their need for personalized support.

E-therapies in England for stress, anxiety or depression: what is being used in the NHS? A survey of mental health services

OBJECTIVE

To document the range of web and smartphone apps used and recommended for stress, anxiety or depression by the National Health Service (NHS) in England.

DESIGN

The study was conducted using Freedom of Information (FOI) requests and systematic website searches.

DATA SOURCES

Data were collected via FOI requests to NHS services between 13 February 2015 and 31 March 2015, and searches conducted on NHS apps library websites between 26 March 2015 and 2 November 2015.

DATA COLLECTION/EXTRACTION METHODS

Data were compiled from responses to: (1) FOI requests sent to all Improving Access to Psychological Therapies (IAPT) services and NHS Mental Health Trusts in England and (2) NHS apps library search results.

RESULTS

A total of 61 (54.95%) out of the then 111 IAPT service providers responded, accounting for 191 IAPT services, and all 51 of the then NHS Mental Health Trusts responded. The results were that 13 different web apps and 35 different smartphone apps for depression, anxiety or stress were available through either referral services or the online NHS Apps Libraries. The apps used and recommended vary by area and by point of access (online library/IAPT/trust).

CONCLUSIONS

Future research is required to establish the evidence base for the apps that are being used in the NHS in England. There is a need for service provision to be based on evidence and established guidelines.

Web-based interventions for youth internalizing problems: a systematic review

OBJECTIVE

To review published reports on Web-based treatment and prevention programs for depression, anxiety, and suicide prevention in children, adolescents, and emerging adults.

METHOD

A systematic search of the PsycINFO, PubMed, Medline, and Web of Science databases was conducted in December 2013. Programs were classified according to evidence-base level (Well-Established, Probably Efficacious, Possibly Efficacious, Experimental, and Of Questionable Efficacy).

RESULTS

Of the 14,001 citations initially identified, 25 articles met inclusion criteria for Web-based interventions. These described 9 programs, of which 8 were Internet based and 1 was a mobile application. No Web-based interventions for suicide prevention were identified. Of the randomized controlled trials (n = 14) and open trials (n = 3) identified, 10 reported significant postintervention reductions in symptoms of depression and/or anxiety or improvements in diagnostic ratings, with small to large effect sizes. Many of these studies also reported significant improvements at follow-up. The methodological quality of the studies varied. Many programs were limited by their small sample sizes and use of waitlist or no-treatment control groups.

CONCLUSION

There is limited evidence for the effectiveness of Web-based interventions for youth depression and anxiety. Additional research and program development are needed to fill the current gaps in the literature.

State of the e-mental health field in Australia: where are we now?

OBJECTIVE

E-mental health technologies are increasing rapidly, both in number and in utilisation by consumers, health systems and researchers. This review aimed to: (i) examine the features and scientific evidence for e-mental health programs; (ii) describe the growth in these programs in the past decade, and track the extent and quality of scientific research over time; and (iii) examine Australian and international contribution to the field.

METHOD

Two types of e-mental health programs; 'web interventions' and mobile applications'; targeting depression, bipolar disorder, generalised anxiety disorder, social anxiety, panic disorder and general stress were included. Data were collected from the Beacon website (www.beacon.anu.edu.au; last updated July 2011). Features of each program and their supporting scientific evidence were coded.

RESULTS

In total, 62 web interventions and 11 mobile applications were identified. Half of these were developed in Australia. The majority of programs were aimed towards adults and were based upon cognitive behavioural therapy. Approximately equal numbers of programs were developed for all targeted disorders except bipolar disorder, which was underrepresented. Only 35.5% of programs, all of which were web-based, had been evaluated by at least one RCT. The number of publications over the last decade is increasing. The majority were from Australian sources. Non-Australian research was lower in diversity and quantity.

CONCLUSIONS

E-mental health research is increasing globally. Australia continues to be an international leader in this field. Depression, anxiety and panic disorder remain the disorders most targeted. Whilst the scientific evidence supporting e-mental health programs is growing, a substantial lack of high-quality empirical support was evident across the field, particularly for mobile applications and bipolar and social anxiety.

Reaching out to people struggling with their lives: a discourse analysis of answers from Internet-based services in Norway and Sweden

The Internet has enlarged the scope of human communication, opening new avenues for connecting with people who are struggling with their lives. This article presents a discourse analysis of 101 responses to 98 questions that were posted on 14 different Internet-based mental health services in Norway and Sweden. We aimed to examine and describe the dominant understandings and favored recommendations in the services' answers, and we reflected upon the social consequences of those answers. The services generally understood life struggles as an abnormal state of mind, life rhythms, or self-reinforcing loops. Internet-based mental health services primarily counsel service users to seek help, talk to health care professionals face-to-face, and discuss their life struggles openly and honestly. They also urge service users to take better care of themselves and socialize with other people. However, such answers might enhance the individualization of life problems, masking social origin and construction. Consequently, the services are challenged to include social explanations in their answers and strengthen their responsibility to amplify peoples' messages at a societal level. Potentially, such answers could strengthen democratic structures and put pressure on social equity.

Struggles for recognition: a content analysis of messages posted on the Internet

Background

The Internet has enlarged the possibilities of human communication and opened new ways of exploring perceptions of mental health. This study is part of a research project aiming to explore, describe, and analyze different discourses of mental health in Norway and Sweden, using material from Internet-based services.

Aim

To examine messages posed by users of publicly available question-and-answer services and to describe their content.

Methods

A Web search was used to identify Norwegian and Swedish Websites offering mental health services by email or posted messages. A total of 601 messages from 20 services, 10 Norwegian and 10 Swedish, were analyzed by means of qualitative content analysis and further interpreted in light of the social theory of recognition by Honneth.

Results

Eight categories emerged from the analysis: family life, couples, others, violence, the ungovernable, self-image, negotiating normality, and life struggles. These categories were then grouped into three themes: (1) relationship to significant others, (2) relationship to self, and (3) relationship to the social community. The themes promoted an understanding of mental health as closely connected to political and social factors.

Conclusions

The results showed a variety of concerns from various parts of life and empowered the view that mental health should be understood broadly, at a conceptual level. Mental health emerged as a deeply relational concept that emphasized the equal distribution of chances in life. It strengthened the moral grammar of social inclusion and the acceptance of plurality in social life.