1
|
Horwitz AG, Mills ED, Sen S, Bohnert ASB. Comparative Effectiveness of Three Digital Interventions for Adults Seeking Psychiatric Services: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2422115. [PMID: 39023893 PMCID: PMC11258584 DOI: 10.1001/jamanetworkopen.2024.22115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/14/2024] [Indexed: 07/20/2024] Open
Abstract
Importance There is a substantial gap between demand for and availability of mental health services. Digital mental health interventions (DMHIs) are promising tools for bridging this gap, yet little is known about their comparative effectiveness. Objective To assess whether patients randomized to a cognitive behavioral therapy (CBT)-based or mindfulness-based DMHI had greater improvements in mental health symptoms than patients randomized to the enhanced personalized feedback (EPF)-only DMHI. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted between May 13, 2020, and December 12, 2022, with follow-up at 6 weeks. Adult patients of outpatient psychiatry services across various clinics within the University of Michigan Health System with a scheduled or recent outpatient psychiatry appointment were recruited. Eligible patients were randomized to an intervention arm. All analyses followed the intent-to-treat principle. Interventions Participants were randomized to 1 of 5 intervention arms: (1) EPF only; (2) Silvercloud only, a mobile application designed to deliver CBT strategies; (3) Silvercloud plus EPF; (4) Headspace only, a mobile application designed to train users in mindfulness practices; and (5) Headspace plus EPF. Main Outcomes and Measures The primary outcome was change in depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9; score range: 0-27, with higher scores indicating greater depression symptoms). Secondary outcomes included changes in anxiety, suicidality, and substance use symptoms. Results A total of 2079 participants (mean [SD] age, 36.8 [14.3] years; 1423 self-identified as women [68.4%]) completed the baseline survey. The baseline mean (SD) PHQ-9 score was 12.7 (6.4) and significantly decreased for all 5 intervention arms at 6 weeks (from -2.1 [95% CI, -2.6 to -1.7] to -2.9 [95% CI, -3.4 to -2.4]; n = 1885). The magnitude of change was not significantly different across the 5 arms (F4,1879 = 1.19; P = .31). Additionally, the groups did not differ in decrease in anxiety or substance use symptoms. However, the Headspace arms reported significantly greater improvements on a suicidality measure subscale compared with the Silvercloud arms (mean difference in mean change = 0.63; 95% CI, 0.20-1.06; P = .004). Conclusions and Relevance This randomized clinical trial found decreases in depression and anxiety symptoms across all DMHIs and minimal evidence that specific applications were better than others. The findings suggest that DMHIs may provide support for patients during waiting list-related delays in care. Trial Registration ClinicalTrials.gov Identifier: NCT04342494.
Collapse
Affiliation(s)
- Adam G. Horwitz
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Elizabeth D. Mills
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Srijan Sen
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Molecular and Behavioral Neuroscience Institute, University of Michigan Medical School, Ann Arbor
| | - Amy S. B. Bohnert
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
2
|
Terhorst Y, Kaiser T, Brakemeier EL, Moshe I, Philippi P, Cuijpers P, Baumeister H, Sander LB. Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2423241. [PMID: 39023887 PMCID: PMC11258589 DOI: 10.1001/jamanetworkopen.2024.23241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024] Open
Abstract
Importance While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary. Objective To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness. Data Sources A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials. Study Selection Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design. Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted. Main Outcomes and Measures Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs. Results The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46). Conclusions and Relevance In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.
Collapse
Affiliation(s)
- Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany
- Department of Psychology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tim Kaiser
- Methods and Evaluation/Quality Assurance, Freie Universität Berlin, Berlin, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, University Greifswald, Greifswald, Germany
| | - Isaac Moshe
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paula Philippi
- Department of Clinical Child and Adolescent Psychology and Psychotherapy, Bergische Universität Wuppertal, Wuppertal, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro-, and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany
| | - Lasse Bosse Sander
- Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
3
|
De Jesús-Romero R, Holder-Dixon AR, Buss JF, Lorenzo-Luaces L. Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review. J Med Internet Res 2024; 26:e50780. [PMID: 38300699 PMCID: PMC10870215 DOI: 10.2196/50780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature. OBJECTIVE Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence. METHODS Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures. RESULTS A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics. CONCLUSIONS It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions.
Collapse
Affiliation(s)
- Robinson De Jesús-Romero
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
| | - Amani R Holder-Dixon
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - John F Buss
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
| | - Lorenzo Lorenzo-Luaces
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
| |
Collapse
|
4
|
Aguilera A, Arévalo Avalos MR, Rosales K, Reyes Y, Hernandez-Ramos R, Ramos G, Garcia E, Hoang T, Ochoa-Frongia L, Fortuna LR, Schueller SM. Effectiveness-implementation hybrid trial of Spanish language, digital cognitive-behavioral therapy (dCBT) intervention for depression and anxiety - protocol for the SUPERA (SUpport from PEeRs to expand Access) study. Contemp Clin Trials 2024; 137:107422. [PMID: 38145715 PMCID: PMC11138320 DOI: 10.1016/j.cct.2023.107422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Limited English Proficiency (LEP) Latinxs experience a longer duration of untreated depression and anxiety. LEP Latinxs have difficulty accessing mental healthcare due to insufficient Spanish-speaking behavioral/mental health clinicians to meet demand. These under-resourced healthcare systems are less likely to be the site for the implementation of innovations. Digital interventions can provide an effective option for overcoming these barriers; yet, when digital evidence-based treatments are available, uptake and engagement is often low. This manuscript presents the protocol for the SUPERA (SUpport from PEeRs to expand Access) study which will evaluate the implementation of an evidence-based, Spanish language, digital cognitive-behavioral therapy (dCBT) intervention (i.e., SilverCloud) in safety-net primary care clinics for LEP Latinx patients with depression or anxiety. METHODS We will conduct an effectiveness-implementation hybrid trial (Type 2) design comparing engagement and clinical outcomes in two modalities of dCBT delivery (peer-supported vs. unsupported). We will also compare provider-level outreach (using a clinic patient registry) versus inreach (traditional provider referral) to compare rates of initiation, completion, and cost. Participants will be 426 LEP Latinx adults ≥18 years of age, PHQ-9 ≥ 10 or GAD-7 ≥ 8, with access to the internet via smartphone, and not currently receiving individual psychotherapy. We will collect baseline, post-intervention (8 weeks), and follow up (3 months) data. CONCLUSION The long-term goal of this research is to aid in the implementation of digital mental health interventions that can be sustainably implemented in low-resourced settings, while reducing the reliance on professionals, overcoming workforce deficits, and increasing relevance for diverse populations.
Collapse
Affiliation(s)
- Adrian Aguilera
- School of Social Welfare, University of California Berkeley, Berkeley, CA, United States of America; Department of Psychiatry, University of California-San Francisco, San Francisco, CA, United States of America.
| | - Marvyn R Arévalo Avalos
- School of Social Welfare, University of California Berkeley, Berkeley, CA, United States of America
| | - Karina Rosales
- School of Social Welfare, University of California Berkeley, Berkeley, CA, United States of America
| | - Yazleen Reyes
- Department of Psychological Science, University of California Irvine, Irvine, CA, United States of America
| | - Rosa Hernandez-Ramos
- Department of Psychological Science, University of California Irvine, Irvine, CA, United States of America
| | - Giovanni Ramos
- Department of Psychological Science, University of California Irvine, Irvine, CA, United States of America
| | - Esmeralda Garcia
- School of Social Welfare, University of California Berkeley, Berkeley, CA, United States of America
| | - Tuyen Hoang
- Biostatistics, Epidemiology & Research Design (BERD) Unit, University of California, Irvine, Irvine, CA, United States of America
| | - Lisa Ochoa-Frongia
- School of Medicine, University of California-San Francisco, San Francisco, CA, United States of America
| | - Lisa R Fortuna
- Department of Psychiatry, University of California-San Francisco, San Francisco, CA, United States of America
| | - Stephen M Schueller
- Department of Psychological Science, University of California Irvine, Irvine, CA, United States of America
| |
Collapse
|
5
|
Fitzsimmons-Craft EE, Rojas E, Topooco N, Rackoff GN, Zainal NH, Eisenberg D, Shah J, Desage C, Wilfley DE, Taylor CB, Newman MG. Training, supervision, and experience of coaches offering digital guided self-help for mental health concerns. Front Psychol 2023; 14:1217698. [PMID: 38078269 PMCID: PMC10698738 DOI: 10.3389/fpsyg.2023.1217698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/19/2023] [Indexed: 02/12/2024] Open
Abstract
Accessible, low-cost intervention options are necessary to address the rise in mental health problems among college students. Digital guided self-help, or coached, programs have been developed to provide such services, with many commercially available. As such, there are a large and growing number of individuals coaching these programs. However, an unmet need is to evaluate and assess best practices for training and supervising individuals in these positions. To this end, we describe how we recruited, trained, and supervised coaches as part of a large randomized controlled trial using a widely available digital commercial platform. Coaches were trained to provide digital guided self-help for depression, anxiety, and/or eating disorders for college students. Coaches initially attended three live training sessions over 2-3 weeks, viewed multiple training videos, and read a detailed coaching manual developed by our team. Thereafter, they attended weekly supervision. Following their term, coaches completed an exit survey to assess their supervision and training experiences. A total of 37 of 70 (53%) graduate-level student coaches completed the survey. The experience was reported as very positive (95%). In particular, the majority reported feeling well prepared, more confident, and felt they had developed useful skills for their own practice.
Collapse
Affiliation(s)
- Ellen E. Fitzsimmons-Craft
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Elsa Rojas
- Center for m (2) Health, Palo Alto University, Palo Alto, CA, United States
| | - Naira Topooco
- Center for m (2) Health, Palo Alto University, Palo Alto, CA, United States
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Gavin N. Rackoff
- Department of Psychology, State College, Penn State University, University Park, PA, United States
| | - Nur Hani Zainal
- Harvard Medical School, Department of Healthcare Policy, Boston, MA, United States
| | - Daniel Eisenberg
- Department of Health Policy and Management, Fielding School of Public Health at UCLA, Ann Arbor, MI, United States
| | - Jillian Shah
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Christina Desage
- Children and Adolescents Psychotherapy and Technology Lab, Palo Alto University, Palo Alto, CA, United States
| | - Denise E. Wilfley
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Craig Barr Taylor
- Center for m (2) Health, Palo Alto University, Palo Alto, CA, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Michelle G. Newman
- Department of Psychology, State College, Penn State University, University Park, PA, United States
| |
Collapse
|
6
|
Duffy D, Richards D, Earley C, Timulak L. Implementing internet-delivered cognitive behavioral therapy in healthcare services: a qualitative exploration of stakeholder experience. Front Digit Health 2023; 5:1139125. [PMID: 37822855 PMCID: PMC10562631 DOI: 10.3389/fdgth.2023.1139125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 09/11/2023] [Indexed: 10/13/2023] Open
Abstract
Background This study consisted of a qualitative exploration of stakeholder experience regarding the implementation of internet-delivered cognitive behavioral therapy (iCBT) as part of routine service provision within the UK's Improving Access to Psychological Therapies program. Methods Stakeholder groups included service providers (n = 6), commercial iCBT representatives (n = 6) and patients who received a course of iCBT as part of treatment at the service (n = 7). Participants took part in a semi-structured interview over the telephone, and subsequent data were qualitatively analyzed using the descriptive-interpretive approach. Results Service providers highlighted the importance of effective leadership and management, training initiatives, the provision of feedback to commercial iCBT representatives and creating work structures around iCBT to facilitate iCBT supporting staff in their use of it. Commercial iCBT representatives similarly reported the importance of training clinicians in iCBT use, identifying the appropriate individuals at all levels of the service to drive iCBT implementation, and the importance of being responsive to any problems or needs that arise from the service. Patients reported an overall positive experience of receiving iCBT but highlighted a need for more information from their supporter and the intervention to better structure their usage. Contextual factors, in terms of barriers and facilitators, were also highlighted by service provider and commercial participants; citing negative clinician attitudes and technological issues/bugs as barriers to implementation, and the exposure to iCBT created by COVID-19 and perseverance in using iCBT over time as facilitators. Discussion The findings contribute to a growing field of literature that seeks to understand the experience of relevant stakeholders who are involved with and contribute to iCBT implementation, including commercial iCBT representatives who, to our knowledge, have not been accounted for as part of published research to date.
Collapse
Affiliation(s)
- Daniel Duffy
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
- School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Derek Richards
- SilverCloud Science, SilverCloud Health, Dublin, Ireland
- School of Psychology, Trinity College Dublin, Dublin, Ireland
| | | | | |
Collapse
|
7
|
Lin Z, Cheng L, Han X, Wang H, Liao Y, Guo L, Shi J, Fan B, Teopiz KM, Jawad MY, Zhang H, Chen Y, Lu C, McIntyre RS. The Effect of Internet-Based Cognitive Behavioral Therapy on Major Depressive Disorder: Randomized Controlled Trial. J Med Internet Res 2023; 25:e42786. [PMID: 37738092 PMCID: PMC10559190 DOI: 10.2196/42786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/10/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Many people living with major depressive disorder (MDD) in China do not receive treatment owing to a lack of mental health services, along with significant stigma toward mental illness. Internet-based cognitive behavioral therapy (ICBT) has been proposed to increase access to mental health care for people with MDD. OBJECTIVE The aims of this study were to (1) evaluate the efficacy of ICBT for depressive symptoms in patients with MDD; (2) evaluate the effect of ICBT on anxiety symptoms, nonspecific psychological distress, general self-efficacy, depression stigma, social function, and health-related quality of life (HRQoL); and (3) explore the acceptability of and satisfaction with the ICBT program among participants. METHODS Patients with MDD were enrolled and randomized to the ICBT group or the waiting-list control (WLC) group. The ICBT group received ICBT delivered through a WeChat mini-program with general support by nonspecialists. Participants in the 2 groups were self-evaluated online at baseline and posttreatment for changes in the primary outcome (ie, depressive symptoms) and secondary outcomes (ie, anxiety symptoms, nonspecific psychological distress, general self-efficacy, depression stigma, social functional impairment, and HRQoL). Changes in outcomes were measured by changes in overall scores on respective scales, and response and remission rates were calculated based on depressive symptoms. The acceptability of and satisfaction with the ICBT program were measured by treatment adherence and participants' feelings (ie, modules seriously completed, perceived benefit, and satisfaction). RESULTS We included 40 patients who were randomly assigned to the ICBT group and 44 who were assigned to the WLC group. Compared with the WLC group, the ICBT group had fewer depressive symptoms, fewer anxiety symptoms, less nonspecific psychological distress, and greater general self-efficacy. Moreover, the ICBT group had higher response (18/31, 58%) and remission rates (17/31, 55%). The adherence rate in the ICBT group was 78% (31/40), and the majority of participants who completed all ICBT modules were satisfied with the ICBT program. CONCLUSIONS ICBT demonstrated greater improvements in depressive symptoms, anxiety symptoms, nonspecific psychological distress, and general self-efficacy among selected patients with MDD in comparison with the findings in waiting-list controls. The ICBT program in this study had good acceptability and satisfaction among participants. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2100046425); https://tinyurl.com/bdcrj4zv.
Collapse
Affiliation(s)
- Ziyi Lin
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Engineering Technology Research Center of Nutrition Translation, Guangzhou, China
| | - Lu Cheng
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Xue Han
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Hongqiong Wang
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Engineering Technology Research Center of Nutrition Translation, Guangzhou, China
| | - Yuhua Liao
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Engineering Technology Research Center of Nutrition Translation, Guangzhou, China
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Lan Guo
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Engineering Technology Research Center of Nutrition Translation, Guangzhou, China
| | - Jingman Shi
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Engineering Technology Research Center of Nutrition Translation, Guangzhou, China
| | - Beifang Fan
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Kayla M Teopiz
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Muhammad Youshay Jawad
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | - Huimin Zhang
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Yan Chen
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Ciyong Lu
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Sun Yat-sen University, Guangzhou, China
- Guangdong Engineering Technology Research Center of Nutrition Translation, Guangzhou, China
| | - Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
8
|
Pigeon WR, Bishop TM, Bossarte RM, Schueller SM, Kessler RC. A two-phase, prescriptive comparative effectiveness study to optimize the treatment of co-occurring insomnia and depression with digital interventions. Contemp Clin Trials 2023; 132:107306. [PMID: 37516163 DOI: 10.1016/j.cct.2023.107306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Insomnia and depression frequently co-occur. Significant barriers preclude a majority of patients from receiving first line treatments for both disorders in a sequential treatment episode. Although digital versions of cognitive behavioral therapy for insomnia (CBTI) and for depression (CBTD) hold some promise to meet demand, especially when paired with human support, it is unknown whether heterogeneity of treatment effects exist, such that some patients would be optimally treated with single or sequential interventions. OBJECTIVE Describe the protocol for a two-phase, prescriptive comparative effectiveness study to develop and evaluate an individualized intervention rule (IIR) for prescribing the optimal digital treament of co-occurring insomnia and depression. METHODS The proposed sample size is 2300 U.S. military veterans with insomnia and depression recruited nationally (Phase 1 = 1500; Phase 2 = 800). In each phase, the primary endpoint will be remission of both depression and insomnia 3 months following a 12-week intervention period. Phase 1 is a 5-arm randomized trial: two single digital interventions (CBT-I or CBT-D); two sequenced interventions (CBT-I + D or CBT-D + I); and a mood monitoring control condition. A cutting-edge ensemble machine learning method will be used to develop the IIR. Phase 2 will evaluate the IIR by randomizing participants with equal allocation to either the IIR predicted optimal intervention for that individual or by randomization to one the four CBT interventions. RESULTS Study procedures are ongoing. Results will be reported in future manuscripts. CONCLUSION The study will generate evidence on the optimal scalable approach to treat co-occurring insomnia and depression.
Collapse
Affiliation(s)
- Wilfred R Pigeon
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Boulevard - Box PSYCH, Rochester, NY 14642, USA; U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention (37B), Canandaigua VA Medical Center, 400 Fort Hill Ave, Canandaigua, NY 14424, USA.
| | - Todd M Bishop
- Sleep and Neurophysiology Research Laboratory, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Boulevard - Box PSYCH, Rochester, NY 14642, USA; U.S. Department of Veterans Affairs Center of Excellence for Suicide Prevention (37B), Canandaigua VA Medical Center, 400 Fort Hill Ave, Canandaigua, NY 14424, USA
| | - Robert M Bossarte
- Department of Psychiatry and Behavioral Neurology, University of South Florida, 3515 E. Fletcher Ave Tampa, FL 33620, USA
| | - Stephen M Schueller
- Department of Health Care Policy, Harvard Medical School, 108 Longwood Ave, Boston, MA 02115, USA
| | - Ronald C Kessler
- Department of Psychological Science, University of California at Irvine, 4341 Social and Behavioral Sciences Gateway, 214 Pereira Dr, Irvine, CA 92617, USA
| |
Collapse
|
9
|
Forbes A, Keleher MR, Venditto M, DiBiasi F. Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review. J Med Internet Res 2023; 25:e43727. [PMID: 37566447 PMCID: PMC10457707 DOI: 10.2196/43727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 04/24/2023] [Accepted: 06/28/2023] [Indexed: 08/12/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ainslie Forbes
- Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, United States
| | | | | | - Faith DiBiasi
- Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, United States
| |
Collapse
|
10
|
Hornstein S, Zantvoort K, Lueken U, Funk B, Hilbert K. Personalization strategies in digital mental health interventions: a systematic review and conceptual framework for depressive symptoms. Front Digit Health 2023; 5:1170002. [PMID: 37283721 PMCID: PMC10239832 DOI: 10.3389/fdgth.2023.1170002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Introduction Personalization is a much-discussed approach to improve adherence and outcomes for Digital Mental Health interventions (DMHIs). Yet, major questions remain open, such as (1) what personalization is, (2) how prevalent it is in practice, and (3) what benefits it truly has. Methods We address this gap by performing a systematic literature review identifying all empirical studies on DMHIs targeting depressive symptoms in adults from 2015 to September 2022. The search in Pubmed, SCOPUS and Psycinfo led to the inclusion of 138 articles, describing 94 distinct DMHIs provided to an overall sample of approximately 24,300 individuals. Results Our investigation results in the conceptualization of personalization as purposefully designed variation between individuals in an intervention's therapeutic elements or its structure. We propose to further differentiate personalization by what is personalized (i.e., intervention content, content order, level of guidance or communication) and the underlying mechanism [i.e., user choice, provider choice, decision rules, and machine-learning (ML) based approaches]. Applying this concept, we identified personalization in 66% of the interventions for depressive symptoms, with personalized intervention content (32% of interventions) and communication with the user (30%) being particularly popular. Personalization via decision rules (48%) and user choice (36%) were the most used mechanisms, while the utilization of ML was rare (3%). Two-thirds of personalized interventions only tailored one dimension of the intervention. Discussion We conclude that future interventions could provide even more personalized experiences and especially benefit from using ML models. Finally, empirical evidence for personalization was scarce and inconclusive, making further evidence for the benefits of personalization highly needed. Systematic Review Registration Identifier: CRD42022357408.
Collapse
Affiliation(s)
- Silvan Hornstein
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kirsten Zantvoort
- Institute of Information Systems, Leuphana University, Lueneburg, Germany
| | - Ulrike Lueken
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Burkhardt Funk
- Institute of Information Systems, Leuphana University, Lueneburg, Germany
| | - Kevin Hilbert
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
11
|
Xiong J, Wen JL, Pei GS, Han X, He DQ. Effectiveness of Internet-based cognitive behavioural therapy for employees with depression: a systematic review and meta-analysis. INTERNATIONAL JOURNAL OF OCCUPATIONAL SAFETY AND ERGONOMICS 2023; 29:268-281. [PMID: 35172706 DOI: 10.1080/10803548.2022.2043647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objectives. The effectiveness of Internet interventions for employees with depressive disorder remains controversial. We summarized all available evidence exploring the role of Internet interventions in reducing employees' depressive symptoms. Methods. This study was a comprehensive systematic review and meta-analysis that included acceptability and preliminary feasibility studies. We excluded programme descriptions, discussion articles and study protocols. We followed the PRISMA guidelines and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Library and Web of Science from database inception to May 2021 for articles published in English. We extracted data concerning demographics, intervention format, including Internet interventions, control group conditions and outcome measures. We used a random-effects model and calculated Hedges' g values for the scores of employees receiving Internet interventions versus control conditions. This systematic review is registered as INPLASY202160082. Results. Data from 19 studies were included. These 19 studies included 5898 participants (2813 participants received Internet interventions, 3085 participants were in control groups). Conclusions. The findings suggest that Internet interventions can be effective in improving depression in employees. However, more randomized controlled trials are needed to provide better evidence regarding Internet interventions for employees with depression, and robust studies are needed to observe the effectiveness of Internet interventions.
Collapse
Affiliation(s)
- Juan Xiong
- School of Marxism, Chongqing University, People's Republic of China
| | - Jian Lin Wen
- School of Marxism, Chongqing University, People's Republic of China
| | - Guang Shu Pei
- School of Marxism, Chongqing University, People's Republic of China
| | - Xu Han
- School of Marxism, Chongqing University, People's Republic of China
| | - Dan Qing He
- School of Humanities, Mianyang Polytechnic, People's Republic of China
| |
Collapse
|
12
|
Gómez Bergin AD, Valentine AZ, Rennick-Egglestone S, Slade M, Hollis C, Hall CL. Identifying and Categorizing Adverse Events in Trials of Digital Mental Health Interventions: Narrative Scoping Review of Trials in the International Standard Randomized Controlled Trial Number Registry. JMIR Ment Health 2023; 10:e42501. [PMID: 36811940 PMCID: PMC9996423 DOI: 10.2196/42501] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/11/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To contextualize the benefits of an intervention, it is important that adverse events (AEs) are reported. This is potentially difficult in trials of digital mental health interventions, where delivery may be remote and the mechanisms of actions less understood. OBJECTIVE We aimed to explore the reporting of AEs in randomized controlled trials of digital mental health interventions. METHODS The International Standard Randomized Controlled Trial Number database was searched for trials registered before May 2022. Using advanced search filters, we identified 2546 trials in the category of mental and behavioral disorders. These trials were independently reviewed by 2 researchers against the eligibility criteria. Trials were included where digital mental health interventions for participants with a mental health disorder were evaluated through a completed randomized controlled trial (protocol and primary results publication published). Published protocols and primary results publications were then retrieved. Data were extracted independently by 3 researchers, with discussion to reach consensus when required. RESULTS Twenty-three trials met the eligibility criteria, of which 16 (69%) included a statement on AEs within a publication, but only 6 (26%) reported AEs within their primary results publication. Seriousness was referred to by 6 trials, relatedness by 4, and expectedness by 2. More interventions delivered with human support (9/11, 82%) than those with only remote or no support (6/12, 50%) included a statement on AEs, but they did not report more AEs. Several reasons for participant dropout were identified by trials that did not report AEs, of which some were identifiable or related to AEs, including serious AEs. CONCLUSIONS There is significant variation in the reporting of AEs in trials of digital mental health interventions. This variation may reflect limited reporting processes and difficulty recognizing AEs related to digital mental health interventions. There is a need to develop guidelines specifically for these trials to improve future reporting.
Collapse
Affiliation(s)
- Aislinn D Gómez Bergin
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Althea Z Valentine
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Stefan Rennick-Egglestone
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
- Faculty of Medicine and Health Sciences, Nord University, Namsos, Norway
| | - Chris Hollis
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Charlotte L Hall
- National Institute for Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| |
Collapse
|
13
|
Morris L, Lovell K, McEvoy P, Emsley R, Carter LA, Edge D, Bates R, Wallwork T, Mansell W. A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial. Cogn Behav Ther 2023; 52:176-197. [PMID: 36625458 DOI: 10.1080/16506073.2022.2143418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.
Collapse
Affiliation(s)
- Lydia Morris
- Division of Psychology & Mental Health, University of Manchester, Coupland 1 Building, Oxford Rd, Manchester M13 9PL, UK
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Greater Manchester Mental Health NHS Foundation Trust, Oxford Rd, Manchester M13 9PL, UK
| | - Phil McEvoy
- Six Degrees Social Enterprise, Greenwood Business Centre, Southwood House, Regent Road, Salford M5 4QH, UK
| | - Richard Emsley
- Institute of Psychiatry, Psychology & Neuroscience, King's College, University of London, 16 De Crespigny Park, London SE5 8AB, UK
| | - Lesley-Anne Carter
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Jean McFarlane Building, Oxford Rd, Manchester M13 9PL, UK
| | - Dawn Edge
- Division of Psychology & Mental Health, University of Manchester, Coupland 1 Building, Oxford Rd, Manchester M13 9PL, UK
| | - Rachel Bates
- Six Degrees Social Enterprise, Greenwood Business Centre, Southwood House, Regent Road, Salford M5 4QH, UK
| | - Tanya Wallwork
- Six Degrees Social Enterprise, Greenwood Business Centre, Southwood House, Regent Road, Salford M5 4QH, UK
| | - Warren Mansell
- School of Population Health, Curtin University, Kent Street, Bentley 6102, Western Australia
| |
Collapse
|
14
|
Balcombe L, De Leo D. Evaluation of the Use of Digital Mental Health Platforms and Interventions: Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010362. [PMID: 36612685 PMCID: PMC9819791 DOI: 10.3390/ijerph20010362] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 05/28/2023]
Abstract
BACKGROUND The increasing use of digital mental health (DMH) platforms and digital mental health interventions (DMHIs) is hindered by uncertainty over effectiveness, quality and usability. There is a need to identify the types of available evidence in this domain. AIM This study is a scoping review identifying evaluation of the (1) DMH platform/s used; and (2) DMHI/s applied on the DMH platform/s. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guided the review process. Empirical studies that focused on evaluation of the use and application of DMH platforms were included from journal articles (published 2012-2022). A literature search was conducted using four electronic databases (Scopus, ScienceDirect, Sage and ACM Digital Library) and two search engines (PubMed and Google Scholar). RESULTS A total of 6874 nonduplicate records were identified, of which 144 were analyzed and 22 met the inclusion criteria. The review included general/unspecified mental health and/or suicidality indications (n = 9, 40.9%), followed by depression (n = 5, 22.7%), psychosis (n = 3, 13.6%), anxiety and depression (n = 2, 9.1%), as well as anxiety, depression and suicidality (n = 1, 4.5%), loneliness (n = 1, 4.5%), and addiction (n = 1, 4.5%). There were 11 qualitative studies (50%), 8 quantitative studies (36.4%), and 3 mixed-methods studies (n = 3, 13.6%). The results contained 11 studies that evaluated the DMH platform/s and 11 studies that evaluated the DMHI/s. The studies focused on feasibility, usability, engagement, acceptability and effectiveness. There was a small amount of significant evidence (1 in each 11), notably the (cost-)effectiveness of a DMHI with significant long-term impact on anxiety and depression in adults. CONCLUSION The empirical research demonstrates the feasibility of DMH platforms and DMHIs. To date, there is mostly heterogeneous, preliminary evidence for their effectiveness, quality and usability. However, a scalable DMHI reported effectiveness in treating adults' anxiety and depression. The scope of effectiveness may be widened through targeted strategies, for example by engaging independent young people.
Collapse
|
15
|
Børtveit L, Dechsling A, Sütterlin S, Nordgreen T, Nordahl-Hansen A. Guided Internet-Delivered Treatment for Depression: Scoping Review. JMIR Ment Health 2022; 9:e37342. [PMID: 36194467 PMCID: PMC9579933 DOI: 10.2196/37342] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/01/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder. OBJECTIVE The aim of this study was to provide an overview of this research area and identify potential gaps in the research. METHODS In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition. RESULTS A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion. CONCLUSIONS This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.
Collapse
Affiliation(s)
- Line Børtveit
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway.,Faculty of Health Sciences, Department of Behavioral Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Anders Dechsling
- Department of Education, ICT, and Learning, Østfold University College, Halden, Norway
| | - Stefan Sütterlin
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway.,Faculty of Computer Science, Albstadt-Sigmaringen University, Sigmaringen, Germany
| | - Tine Nordgreen
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Departement of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Anders Nordahl-Hansen
- Department of Education, ICT, and Learning, Østfold University College, Halden, Norway
| |
Collapse
|
16
|
Cumpanasoiu C, Enrique A, Palacios J, Duffy D, McNamara S, Richards D. Trajectories of symptoms in digital interventions for depression and anxiety using Routine Outcome Monitoring data: A secondary analysis study (Preprint). JMIR Mhealth Uhealth 2022. [PMID: 37436812 PMCID: PMC10372559 DOI: 10.2196/41815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Research suggests there is heterogeneity in treatment response for internet-delivered cognitive behavioral therapy (iCBT) users, but few studies have investigated the trajectory of individual symptom change across iCBT treatment. Large patient data sets using routine outcome measures allows the investigation of treatment effects over time as well as the relationship between outcomes and platform use. Understanding trajectories of symptom change, as well as associated characteristics, may prove important for tailoring interventions or identifying patients who may not benefit from the intervention. OBJECTIVE We aimed to identify latent trajectories of symptom change during the iCBT treatment course for depression and anxiety and to investigate the patients' characteristics and platform use for each of these classes. METHODS This is a secondary analysis of data from a randomized controlled trial designed to examine the effectiveness of guided iCBT for anxiety and depression in the UK Improving Access to Psychological Therapies (IAPT) program. This study included patients from the intervention group (N=256) and followed a longitudinal retrospective design. As part of the IAPT's routine outcome monitoring system, patients were prompted to complete the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) after each supporter review during the treatment period. Latent class growth analysis was used to identify the underlying trajectories of symptom change across the treatment period for both depression and anxiety. Differences in patient characteristics were then evaluated between these trajectory classes, and the presence of a time-varying relationship between platform use and trajectory classes was investigated. RESULTS Five-class models were identified as optimal for both PHQ-9 and GAD-7. Around two-thirds (PHQ-9: 155/221, 70.1%; GAD-7: 156/221, 70.6%) of the sample formed various trajectories of improvement classes that differed in baseline score, the pace of symptom change, and final clinical outcome score. The remaining patients were in 2 smaller groups: one that saw minimal to no gains and another with consistently high scores across the treatment journey. Baseline severity, medication status, and program assigned were significantly associated (P<.001) with different trajectories. Although we did not find a time-varying relationship between use and trajectory classes, we found an overall effect of time on platform use, suggesting that all participants used the intervention significantly more in the first 4 weeks (P<.001). CONCLUSIONS Most patients benefit from treatment, and the various patterns of improvement have implications for how the iCBT intervention is delivered. Identifying predictors of nonresponse or early response might inform the level of support and monitoring required for different types of patients. Further work is necessary to explore the differences between these trajectories to understand what works best for whom and to identify early on those patients who are less likely to benefit from treatment.
Collapse
|
17
|
Bossarte RM, Kessler RC, Nierenberg AA, Chattopadhyay A, Cuijpers P, Enrique A, Foxworth PM, Gildea SM, Belnap BH, Haut MW, Law KB, Lewis WD, Liu H, Luedtke AR, Pigeon WR, Rhodes LA, Richards D, Rollman BL, Sampson NA, Stokes CM, Torous J, Webb TD, Zubizarreta JR. The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients. Trials 2022; 23:520. [PMID: 35725644 PMCID: PMC9207842 DOI: 10.1186/s13063-022-06438-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/29/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems. METHODS Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE. DISCUSSION The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT. TRIAL REGISTRATION ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.
Collapse
Affiliation(s)
- Robert M Bossarte
- Department of Psychiatry and Behavioral Neuroscience, University of South Florida, 3515 E. Fletcher Ave, FL, 33613, Tampa, USA.
| | - Ronald C Kessler
- Department of Healthcare Policy, Harvard Medical School, Boston, MA, USA
| | - Andrew A Nierenberg
- The Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 7-9, Amsterdam, 1081 BT, The Netherlands
| | - Angel Enrique
- E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College Dublin and Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | | | - Sarah M Gildea
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Bea Herbeck Belnap
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marc W Haut
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, WV, USA.,Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, USA.,Department of Radiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kari B Law
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, WV, USA
| | - William D Lewis
- Department of Family Medicine, West Virginia University School of Medicine and West Virginia University Clinical and Translational Science Institute, Morgantown, WV, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Alexander R Luedtke
- Department of Statistics, University of Washington and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Larry A Rhodes
- Department of Pediatrics, West Virginia University School of Medicine and West Virginia University Institute for Community and Rural Health, Morgantown, WV, USA
| | - Derek Richards
- E-mental Health Research Group, School of Psychology, University of Dublin, Trinity College Dublin and Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Bruce L Rollman
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nancy A Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Cara M Stokes
- Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, WV, USA.,West Virginia University Injury Control Research Center, Morgantown, WV, USA
| | - John Torous
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tyler D Webb
- Department of Psychiatry and Behavioral Neuroscience, University of South Florida, 3515 E. Fletcher Ave, FL, 33613, Tampa, USA
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Department of Statistics, Harvard University, Cambridge, MA, USA.,Department of Biostatistics, Harvard University, Cambridge, MA, USA
| |
Collapse
|
18
|
Daniore P, Nittas V, von Wyl V. Enrollment and retention of participants in remote digital health studies: a scoping review and framework proposal (Preprint). J Med Internet Res 2022; 24:e39910. [PMID: 36083626 PMCID: PMC9508669 DOI: 10.2196/39910] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions
Collapse
Affiliation(s)
- Paola Daniore
- Institute for Implementation Science in Healthcare, University of Zurich, Zurich, Switzerland
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
| | - Vasileios Nittas
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Viktor von Wyl
- Institute for Implementation Science in Healthcare, University of Zurich, Zurich, Switzerland
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| |
Collapse
|
19
|
Richardson T, Enrique A, Earley C, Adegoke A, Hiscock D, Richards D. The Acceptability and Initial Effectiveness of “Space From Money Worries”: An Online Cognitive Behavioral Therapy Intervention to Tackle the Link Between Financial Difficulties and Poor Mental Health. Front Public Health 2022; 10:739381. [PMID: 35493363 PMCID: PMC9046654 DOI: 10.3389/fpubh.2022.739381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 03/08/2022] [Indexed: 12/03/2022] Open
Abstract
Background Previous research has shown a strong relationship between financial difficulties and mental health problems. Psychological factors such as hope and worry about finances appear to be an important factor in this relationship. Objective To develop an online based psychological intervention (Space from Money Worries) to tackle the psychological mechanisms underlying the relationship between poor mental health and financial difficulties, and to conduct an initial evaluation of the acceptability and preliminary efficacy of the intervention. Materials and Methods 30 participants accessing Increasing Access to Psychological Therapies (IAPT) services completed GAD-7 to measure anxiety and PHQ-9 to measure depression upon signing up to the online intervention and again 4 to 8 weeks after this. Participants also completed a measure of perceived financial distress/wellbeing and a “Money and Mental Health Scale” constructed for the evaluation. Results Overall, 77% (n = 23) completed the intervention and follow-up assessments. Intent to Treat Analysis showed that there were statistically significant improvements in symptoms of depression, anxiety, improved perceived financial wellbeing and reduced scores on the money and mental health scale. The vast majority of participants rated each module positively. Conclusions Space from Money Worries appears to be acceptable and may lead to improvements in mental health, perceived financial wellbeing and a reduced relationship between financial difficulties and poor mental health. However, future research with a larger sample and a control group are needed to confirm that these changes are due to the intervention.
Collapse
Affiliation(s)
- Thomas Richardson
- Richardson Psychological Consultation Limited, The Psychotherapy Practice, Southampton, United Kingdom
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- *Correspondence: Thomas Richardson
| | - Angel Enrique
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Research Group, School of Psychology, University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Caroline Earley
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Adedeji Adegoke
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Douglas Hiscock
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Derek Richards
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Research Group, School of Psychology, University of Dublin, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
20
|
Mekonen T, Ford S, Chan GCK, Hides L, Connor JP, Leung J. What is the short-term remission rate for people with untreated depression? A systematic review and meta-analysis. J Affect Disord 2022; 296:17-25. [PMID: 34583099 DOI: 10.1016/j.jad.2021.09.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Depression is one of the prevalent mental illnesses and leading cause of global disease burden. However, most people with depression do not access treatment. Remission without treatment may occur in some cases of depression. This study aimed to estimate the short-term remission (natural recovery) from untreated depression. METHODS A systematic review and meta-analysis was registered on PROSPERO and conducted following PRISMA guidelines. EMBASE, PsycINFO, and PubMed were searched, supplemented with an additional hand search to identify studies reporting natural recovery from untreated depression. Study selection and screening were carried out by three independent reviewers. Methodological quality assessment of the included studies was conducted. Remission was defined as no longer meeting the diagnostic criteria or scoring below the cut off points of the validated tools as reported by the included studies. The data were synthesized using narrative summary and random-effects meta-analysis. RESULTS Sixteen waitlist-controlled trial studies were included in the systematic review and meta-analysis. The duration of follow-up ranged from 4 to 12 weeks with a median duration of 8 weeks. The overall pooled remission from untreated depression was 12.5%, 95% confidence interval (7.8, 18.0%). Due to lack of published data, we were unable to determine if the severity of depression symptoms was associated with remission rates. CONCLUSIONS Short-term remission from depression without treatment is uncommon. Across studies, 8 - 18% of people remitted without treatment within 12 weeks. Waitlist control groups may not represent all persons with depression.
Collapse
Affiliation(s)
- Tesfa Mekonen
- School of Psychology, The University of Queensland, Australia; Psychiatry Department, Bahir Dar University, Ethiopia; National Centre for Youth Substance Use Research, The University of Queensland, Australia.
| | - Sarah Ford
- School of Psychology, The University of Queensland, Australia
| | - Gary C K Chan
- National Centre for Youth Substance Use Research, The University of Queensland, Australia
| | - Leanne Hides
- School of Psychology, The University of Queensland, Australia; National Centre for Youth Substance Use Research, The University of Queensland, Australia
| | - Jason P Connor
- National Centre for Youth Substance Use Research, The University of Queensland, Australia; Discipline of Psychiatry, The University of Queensland, Australia
| | - Janni Leung
- School of Psychology, The University of Queensland, Australia; National Centre for Youth Substance Use Research, The University of Queensland, Australia
| |
Collapse
|
21
|
Clinical wisdom in the age of computer apps: a systematic review of four functions that may complement clinical treatment. COGNITIVE BEHAVIOUR THERAPIST 2022. [DOI: 10.1017/s1754470x22000368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Mental health clinicians perform complex tasks with patients that potentially could be improved by the massive computing power available through mobile apps. This study aimed to analyse commercially available mobile and computer applications (apps) focused on treating psychiatric disorders. Apps were analysed by two independent raters for whether they took advantage of computer power to process data in a fashion that augments four main elements of clinical treatment including (1) assessment/diagnosis, (2) treatment planning, (3) treatment fidelity monitoring, and (4) outcome tracking. The evidence base for each of these apps was also explored via PsychINFO, Research Gate and Google Scholar. Searches of the Google Play Store, the Apple App Store, and the One Mind PsyberGuide found 722 apps labelled for mental health use, of which 163 apps were judged relevant to clinical work with patients with psychiatric disorders. Fifty-nine of these were determined to contain a computer-driven function for at least one of the four main elements of clinical treatment. The most common element was assessment/diagnosis (55/59 apps), followed by outcome tracking (34/59 apps). Six apps updated treatment plans using user input. Only one app tracked treatment fidelity. None of the apps contained computer-driven functions for all four elements. Twelve apps were supported in randomized clinical trials to show greater efficacy compared with either wait-list or other active treatments. Results showed that these four clinical elements can be meaningfully augmented, but the full potential of computer processing appears unreached in mental health-related apps.
Key learning aims
(1)
To understand what apps are currently available to treat clinical-level psychiatric problems.
(2)
To understand how many of the commercially available mental health-focused apps can be used for the treatment of clinical populations.
(3)
To understand how mental health services can be complemented by utilizing computer processing power within apps.
Collapse
|
22
|
Six SG, Byrne KA, Tibbett TP, Pericot-Valverde I. Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis. JMIR Ment Health 2021; 8:e32199. [PMID: 34847058 PMCID: PMC8669581 DOI: 10.2196/32199] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification. OBJECTIVE The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements. METHODS A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis. RESULTS A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=-0.27, 95% CI -0.36 to -0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=-0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=-1.93, SE=2.28; P=.40). CONCLUSIONS The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms.
Collapse
Affiliation(s)
- Stephanie G Six
- Department of Psychology, Clemson University, Clemson, SC, United States
| | - Kaileigh A Byrne
- Department of Psychology, Clemson University, Clemson, SC, United States
| | - Thomas P Tibbett
- SAP National Security Services, Inc, Newtown Square, PA, United States
| | | |
Collapse
|
23
|
Lawler K, Earley C, Timulak L, Enrique A, Richards D. Dropout From an Internet-Delivered Cognitive Behavioral Therapy Intervention for Adults With Depression and Anxiety: Qualitative Study. JMIR Form Res 2021; 5:e26221. [PMID: 34766909 PMCID: PMC8663602 DOI: 10.2196/26221] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/16/2021] [Accepted: 08/01/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Treatment dropout continues to be reported from internet-delivered cognitive behavioral therapy (iCBT) interventions, and lower completion rates are generally associated with lower treatment effect sizes. However, evidence is emerging to suggest that completion of a predefined number of modules is not always necessary for clinical benefit or consideration of the needs of each individual patient. OBJECTIVE The aim of this study is to perform a qualitative analysis of patients' experiences with an iCBT intervention in a routine care setting to achieve a deeper insight into the phenomenon of dropout. METHODS A total of 15 purposively sampled participants (female: 8/15, 53%) from a larger parent randomized controlled trial were interviewed via telephone using a semistructured interview schedule that was developed based on the existing literature and research on dropout in iCBT. Data were analyzed using a descriptive-interpretive approach. RESULTS The experience of treatment leading to dropout can be understood in terms of 10 domains: relationship to technology, motivation to start, background knowledge and attitudes toward iCBT, perceived change in motivation, usage of the program, changes due to the intervention, engagement with content, experience interacting with the supporter, experience of web-based communication, and termination of the supported period. CONCLUSIONS Patients who drop out of treatment can be distinguished in terms of their change in motivation: those who felt ready to leave treatment early and those who had negative reasons for dropping out. These 2 groups of participants have different treatment experiences, revealing the potential attributes and nonattributes of dropout. The reported between-group differences should be examined further to consider those attributes that are strongly descriptive of the experience and regarded less important than those that have become loosely affiliated.
Collapse
Affiliation(s)
- Kate Lawler
- E-Mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland.,Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| | - Caroline Earley
- E-Mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland.,Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| | - Ladislav Timulak
- E-Mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Angel Enrique
- E-Mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland.,Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| | - Derek Richards
- E-Mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland.,Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| |
Collapse
|
24
|
Spanhel K, Balci S, Feldhahn F, Bengel J, Baumeister H, Sander LB. Cultural adaptation of internet- and mobile-based interventions for mental disorders: a systematic review. NPJ Digit Med 2021; 4:128. [PMID: 34433875 PMCID: PMC8387403 DOI: 10.1038/s41746-021-00498-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 08/03/2021] [Indexed: 02/07/2023] Open
Abstract
Providing accessible and effective healthcare solutions for people living in low- and middle-income countries, migrants, and indigenous people is central to reduce the global mental health treatment gap. Internet- and mobile-based interventions (IMI) are considered scalable psychological interventions to reduce the burden of mental disorders and are culturally adapted for implementation in these target groups. In October 2020, the databases PsycInfo, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for studies that culturally adapted IMI for mental disorders. Among 9438 screened records, we identified 55 eligible articles. We extracted 17 content, methodological, and procedural components of culturally adapting IMI, aiming to consider specific situations and perspectives of the target populations. Adherence and effectiveness of the adapted IMI seemed similar to the original IMI; yet, no included study conducted a direct comparison. The presented taxonomy of cultural adaptation of IMI for mental disorders provides a basis for future studies investigating the relevance and necessity of their cultural adaptation.PROSPERO registration number: CRD42019142320.
Collapse
Affiliation(s)
- Kerstin Spanhel
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany.
| | - Sumeyye Balci
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Felicitas Feldhahn
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - Juergen Bengel
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Lasse B Sander
- Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg, Germany
| |
Collapse
|
25
|
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. COGNITIVE THERAPY AND RESEARCH 2021. [DOI: 10.1007/s10608-020-10200-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abstract
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.
Collapse
|
26
|
Lu SHX, Assudani HA, Kwek TRR, Ng SWH, Teoh TEL, Tan GCY. A Randomised Controlled Trial of Clinician-Guided Internet-Based Cognitive Behavioural Therapy for Depressed Patients in Singapore. Front Psychol 2021; 12:668384. [PMID: 34393903 PMCID: PMC8359863 DOI: 10.3389/fpsyg.2021.668384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
This study examined the efficacy and acceptability of a hybrid, clinician-guided internet-based Cognitive Behavioural Therapy (iCBT) programme for outpatients with depression in a psychiatric hospital in Singapore. Fifty three participants were randomly assigned to a treatment or wait-list control group before they underwent a cross-over of conditions. Treatment consisted of a 4-week iCBT with three face-to-face sessions. 60.9% of participants who received treatment completed all six modules. Intention-to-treat analysis showed treatment was associated with significant reductions in symptoms of depression, anxiety and psychological distress but not in functional impairment, while the control condition was not associated with changes in any measures. These reductions had moderate to large effect sizes (ESs) for symptoms of depression and anxiety, and moderate ES for psychological distress. The between-group difference in depression score had a moderate ES. There was a significant between-group treatment effect in depressive symptoms, but not in the other measures. Treatment gains were maintained at 3-month follow-up. Most of the participants were highly satisfied with the programme, with 90 percent stating they would recommend it. This is the first RCT to provide preliminary evidence for the efficacy and acceptability of iCBT for depression in Singapore.
Collapse
Affiliation(s)
- Sharon H X Lu
- Department of Psychology, Institute of Mental Health, Singapore, Singapore
| | - Hanita A Assudani
- Department of Psychology, Institute of Mental Health, Singapore, Singapore
| | - Tammie R R Kwek
- Department of Psychology, Institute of Mental Health, Singapore, Singapore
| | - Shaun W H Ng
- Department of Psychology, Institute of Mental Health, Singapore, Singapore
| | - Trisha E L Teoh
- Department of Psychology, Institute of Mental Health, Singapore, Singapore
| | - Geoffrey C Y Tan
- Department of Mood and Anxiety, Institute of Mental Health, Singapore, Singapore.,Singapore Institute of Clinical Sciences, Agency for Science Technology and Research (ASTAR), Singapore, Singapore.,Clinical Imaging Research Centre, Yong Loo Lin Medical School, National University of Singapore, Singapore, Singapore
| |
Collapse
|
27
|
Is clinician-supported use of a mindfulness smartphone app a feasible treatment for depression? A mixed-methods feasibility study. Internet Interv 2021; 25:100413. [PMID: 34401372 PMCID: PMC8350580 DOI: 10.1016/j.invent.2021.100413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 01/09/2023] Open
Abstract
Depression is the leading cause of disability globally and has serious consequences for the individual, their family and for society. Effective, accessible and affordable treatments are urgently needed. In-person group-based mindfulness-based interventions are an effective treatment for depression, but are not widely available and can be costly. Clinician supported use of mindfulness self-help resources such as mindfulness smartphone applications could widen access at a reduced cost, but there are key feasibility questions that need answering. This is a mixed-methods feasibility study of a blended intervention involving the mindfulness smartphone app Headspace alongside six clinician support sessions with mental health treatment seeking adults experiencing moderate to moderately severe symptoms of depression. In line with recommendations for feasibility studies, we examine whether: (1) it is possible to recruit participants to this novel intervention, (2) participants engage with the intervention, (3) participants and clinicians find the intervention acceptable, and (4) pre-post outcomes on measures of depression (primary outcome), anxiety, wellbeing, mindfulness, self-compassion, rumination and worry indicate effectiveness. Findings show that recruitment is feasible with 54 participants enrolled in the intervention within a 6-month window. In terms of engagement, 44.4% completed at least 80% of recommended Headspace sessions and 72.2% of participants attended at least three clinician support sessions. Clinician-supported Headspace was deemed acceptable by participants and clinicians. Pre-post effect sizes were statistically significant and in the small-medium or medium-large range on all outcomes, with an effect size of d = 0.69 (95% CI: 0.34-1.04) for the primary outcome of depression symptom severity. The number of Headspace sessions engaged with was associated with greater reduction in depression symptom severity. Findings suggest that a blended intervention combining Headspace with clinician support has potential as a first-line treatment for moderate/moderately severe depression, but findings are too preliminary to recommend the intervention outside of a research trial. Important caveats are noted including the need for future research to examine predictors of engagement with Headspace sessions so that engagement can be enhanced, to measure the longer term effects of such interventions and to better understand the potential for lasting negative effects of the intervention so that these can be minimised.
Collapse
|
28
|
Tokgöz P, Hrynyschyn R, Hafner J, Schönfeld S, Dockweiler C. Digital Health Interventions in Prevention, Relapse, and Therapy of Mild and Moderate Depression: Scoping Review. JMIR Ment Health 2021; 8:e26268. [PMID: 33861201 PMCID: PMC8087966 DOI: 10.2196/26268] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/15/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Depression is a major cause for disability worldwide, and digital health interventions are expected to be an augmentative and effective treatment. According to the fast-growing field of information and communication technologies and its dissemination, there is a need for mapping the technological landscape and its benefits for users. OBJECTIVE The purpose of this scoping review was to give an overview of the digital health interventions used for depression. The main goal of this review was to provide a comprehensive review of the system landscape and its technological state and functions, as well as its evidence and benefits for users. METHODS A scoping review was conducted to provide a comprehensive overview of the field of digital health interventions for the treatment of depression. PubMed, PSYNDEX, and the Cochrane Library were searched by two independent researchers in October 2020 to identify relevant publications of the last 10 years, which were examined using the inclusion and exclusion criteria. To conduct the review, we used Rayyan, a freely available web tool. RESULTS In total, 65 studies were included in the qualitative synthesis. After categorizing the studies into the areas of prevention, early detection, therapy, and relapse prevention, we found dominant numbers of studies in the area of therapy (n=52). There was only one study for prevention, 5 studies for early detection, and 7 studies for relapse prevention. The most dominant therapy approaches were cognitive behavioral therapy, acceptance and commitment therapy, and problem-solving therapy. Most of the studies revealed significant effects of digital health interventions when cognitive behavioral therapy was applied. Cognitive behavioral therapy as the most dominant form was often provided through web-based systems. Combined interventions consisting of web-based and smartphone-based approaches are increasingly found. CONCLUSIONS Digital health interventions for treating depression are quite comprehensive. There are different interventions focusing on different fields of care. While most interventions can be beneficial to achieve a better depression treatment, it can be difficult to determine which approaches are suitable. Cognitive behavioral therapy through digital health interventions has shown good effects in the treatment of depression, but treatment for depression still stays very individualistic.
Collapse
Affiliation(s)
- Pinar Tokgöz
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Robert Hrynyschyn
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Health and Nursing Science, Berlin, Germany
| | - Jessica Hafner
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Simone Schönfeld
- School of Public Health, Bielefeld University, Bielefeld, Germany.,LWL-Klinik Lippstadt und Warstein, Lippstadt, Germany.,Universität Witten/Herdecke, Institut für Integrative Gesundheitsversorgung und Gesundheitsförderung, Witten, Germany
| | | |
Collapse
|
29
|
Fitzsimmons-Craft EE, Taylor CB, Newman MG, Zainal NH, Rojas-Ashe EE, Lipson SK, Firebaugh ML, Ceglarek P, Topooco N, Jacobson NC, Graham AK, Kim HM, Eisenberg D, Wilfley DE. Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol. Contemp Clin Trials 2021; 103:106320. [PMID: 33582295 PMCID: PMC8089064 DOI: 10.1016/j.cct.2021.106320] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/27/2021] [Accepted: 02/09/2021] [Indexed: 12/21/2022]
Abstract
About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.
Collapse
Affiliation(s)
- Ellen E Fitzsimmons-Craft
- Department of Psychiatry, Washington University School of Medicine, Mailstop 8134-29-2100, 660 S. Euclid Ave., St. Louis, MO 63110, USA.
| | - C Barr Taylor
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Center for m(2)Health, Palo Alto University, Palo Alto, CA, USA.
| | - Michelle G Newman
- Department of Psychology, Penn State University, University Park, PA, USA.
| | - Nur Hani Zainal
- Department of Psychology, Penn State University, University Park, PA, USA.
| | | | - Sarah Ketchen Lipson
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Marie-Laure Firebaugh
- Department of Psychiatry, Washington University School of Medicine, Mailstop 8134-29-2100, 660 S. Euclid Ave., St. Louis, MO 63110, USA.
| | - Peter Ceglarek
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.
| | - Naira Topooco
- Center for m(2)Health, Palo Alto University, Palo Alto, CA, USA; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
| | - Nicholas C Jacobson
- Departments of Biomedical Data Science and Psychiatry, Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.
| | - Andrea K Graham
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA.
| | - Hyungjin Myra Kim
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA.
| | - Daniel Eisenberg
- Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Denise E Wilfley
- Department of Psychiatry, Washington University School of Medicine, Mailstop 8134-29-2100, 660 S. Euclid Ave., St. Louis, MO 63110, USA.
| |
Collapse
|
30
|
Karyotaki E, Efthimiou O, Miguel C, Bermpohl FMG, Furukawa TA, Cuijpers P. Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry 2021; 78:361-371. [PMID: 33471111 PMCID: PMC8027916 DOI: 10.1001/jamapsychiatry.2020.4364] [Citation(s) in RCA: 304] [Impact Index Per Article: 101.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/23/2020] [Indexed: 12/11/2022]
Abstract
Importance Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. Objective To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. Data Sources We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. Study Selection Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. Data Extraction and Synthesis We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. Main Outcomes and Measures Patient Health Questionnaire-9 (PHQ-9) scores. Results Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9. Conclusions and Relevance In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
Collapse
Affiliation(s)
- Eirini Karyotaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Psychiatry, University of Oxford, Oxford, England
| | - Clara Miguel
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Toshi A. Furukawa
- Department of Clinical Psychology and Psychotherapy, University of Wuppertal, Wuppertal, Germany
- Department of Health Promotion and Human Behavior, Department of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Pim Cuijpers
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | |
Collapse
|
31
|
Przybylko G, Morton DP, Morton JK, Renfrew ME, Hinze J. An interdisciplinary mental wellbeing intervention for increasing flourishing: two experimental studies. THE JOURNAL OF POSITIVE PSYCHOLOGY 2021. [DOI: 10.1080/17439760.2021.1897868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Geraldine Przybylko
- Lifestyle Research Centre, Avondale University College, Cooranbong, Australia
| | - Darren Peter Morton
- Lifestyle Research Centre, Avondale University College, Cooranbong, Australia
| | - Jason Kyle Morton
- Faculty of Education, Business and Science, Avondale University College, Cooranbong, Australia
| | | | - Jason Hinze
- Faculty of Education, Business and Science, Avondale University College, Cooranbong, Australia
| |
Collapse
|
32
|
Integration of a smartwatch within an internet-delivered intervention for depression: Protocol for a feasibility randomized controlled trial on acceptance. Contemp Clin Trials 2021; 103:106323. [PMID: 33621632 DOI: 10.1016/j.cct.2021.106323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/01/2021] [Accepted: 02/12/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mood tracking is commonly employed within a range of mental health interventions. Physical activity and sleep are also important for contextualizing mood data but can be difficult to track manually and rely on retrospective recall. Smartwatches could enhance self-monitoring by addressing difficulties in recall of sleep and physical activity and reducing the burden on patients in terms of remembering to track and the effort of tracking. This feasibility study will explore the acceptance of a smartwatch app for self-monitoring of mood, sleep, and physical activity, in an internet-based cognitive-behavioral therapy (iCBT) for depression offered in a routine care setting. METHODS Seventy participants will be randomly allocated to (i) iCBT intervention plus smartwatch app or (ii) iCBT intervention alone. Patient acceptance will be measured longitudinally using a theory-based acceptance questionnaire to understand and compare the evolution of acceptance of the technology-delivered self-report in the two groups. A post-treatment interview will explore participants subjective experience of using the smartwatch. Engagement with the intervention, including self-report, and clinical outcomes, will be measured across both groups to assess for any differences. IMPLICATIONS This is the first study investigating the evolution of patient acceptance of smartwatch self-report in an iCBT delivered intervention in a clinical sample. Through an engaging and convenient means of capturing ecologically valid mood data, the study has the potential to show that smartwatches are an acceptable means for patient self-monitoring within iCBT interventions for depression and support potential use-cases for smartwatches in the context of mental health interventions in general. Prospectively registered at ClinicalTrials.gov (NCT04568317).
Collapse
|
33
|
Sharif-Sidi Z, Shen C, Wong W, Hanson R, Miller L, Fickel K, Green E, Burns J, Dunn C, Somai M, Crotty BH. Addressing depression and behavioral health needs through a digital program at scale. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100521. [PMID: 33601212 DOI: 10.1016/j.hjdsi.2021.100521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/28/2020] [Accepted: 01/17/2021] [Indexed: 11/19/2022]
Abstract
Depression and anxiety disorders are prevalent mental health conditions; yet they are often unrecognized, under-addressed and/or under-treated, and specialty treatment for these conditions is oftentimes difficult to access. By acting either as a bridge to therapy or as a form of therapy, digital tools, such as those that provide internet-based cognitive behavioral therapy (iCBT), may help clinicians support their patients' mental health needs. At one academic health system, a digital mental health program was deployed in primary care and outpatient behavioral health programs to help patients meet needs identified through screening or clinical visits. Over the first two years of operation, 138 clinicians (40% of eligible clinicians) prescribed the program to 2,228 unique patients, from which 1,117 (48.9%) enrolled. Patients who enrolled tended to be younger and healthier than non-enrollees. On average, enrolled patients spent 114.6 minutes within the iCBT program. Clinical improvement was assessed using pre- and post PHQ-9 and GAD-7 scores for depression and anxiety, respectively. Pre/Post scores were compared using Wilcoxon Rank Sum test. Patients with at least moderate depression had an average 23% reduction in PHQ-9 scores (median change -3(interquartile range 7), p<0.001) and those with at least moderate anxiety had a 26% reduction in GAD-7 scores (-4(7), p<0.001). Improvements were clinically and statistically significant. Future steps include performing a cost analysis to understand whether models utilizing iCBT are net cost-saving for health systems.
Collapse
Affiliation(s)
- Zakariyah Sharif-Sidi
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, United States
| | - Christine Shen
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, United States
| | - William Wong
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, United States
| | - Ryan Hanson
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, United States; Froedtert & Medical College of Wisconsin Health Network, United States
| | - Lawrence Miller
- Department of Psychiatry, Medical College of Wisconsin, United States; Froedtert & Medical College of Wisconsin Health Network, United States
| | - Karen Fickel
- Froedtert & Medical College of Wisconsin Health Network, United States
| | - Erin Green
- Froedtert & Medical College of Wisconsin Health Network, United States
| | - Jaymes Burns
- Froedtert & Medical College of Wisconsin Health Network, United States
| | - Caitlin Dunn
- Froedtert & Medical College of Wisconsin Health Network, United States
| | - Melek Somai
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, United States; Froedtert & Medical College of Wisconsin Health Network, United States
| | - Bradley H Crotty
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, United States; Froedtert & Medical College of Wisconsin Health Network, United States.
| |
Collapse
|
34
|
Akkol-Solakoglu S, Hevey D, Richards D. A randomised controlled trial comparing internet-delivered cognitive behavioural therapy (iCBT) with and without main carer access versus treatment-as-usual for depression and anxiety among breast cancer survivors: Study protocol. Internet Interv 2021; 24:100367. [PMID: 33552931 PMCID: PMC7851185 DOI: 10.1016/j.invent.2021.100367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/08/2021] [Accepted: 01/13/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Depression and anxiety are common problems among breast cancer survivors. Carer support is one of the most important determinants of women's psychological wellbeing. Survivors' distress can be alleviated by giving carers access to survivors' evidence-based treatment, which will help carers understand what survivors have been going through and help survivors feel more supported. Given the limited access to evidence-based treatments, an adapted internet-delivered cognitive behavioural therapy (iCBT) intervention for breast cancer survivors, but also open for carers' access, has the potential to decrease survivors' depression and anxiety symptoms and improve cancer-related communication and relationship quality between survivors and carers. OBJECTIVES This study evaluates (1) the effectiveness of a guided iCBT intervention for depression and/or anxiety symptoms among breast cancer survivors with and without main carer access, and (2) the acceptability and satisfaction with the iCBT programme. METHOD In this pilot study comparing the effectiveness of an adapted 7-week iCBT without main carer access against the iCBT with main carer access and treatment-as-usual control, 108 breast cancer survivors will be recruited and then randomised to either (1) treatment (n = 72) or (2) treatment-as-usual control group (n = 36) with a 2:1 ratio. The participants in the treatment group will be assigned to either iCBT alone or iCBT with the main carer also having access to the same content based on their preference. The primary outcome measure is the Hospital Anxiety and Depression Scale, and alongside secondary measures such as Cancer-Related Quality of Life, Breast Cancer Worry Scale, Brief COPE, and Medical Outcomes Study Social Support Survey will be completed by the survivors at baseline, post-treatment, and 2-month follow-up. Survivors who have carers will also complete Survivor-Carer Cancer Communication and Relationship Quality measures to provide insights into the effects of carer access. To assess the acceptability and satisfaction with the programme, survivors and their main carers will fill out the Helpful Aspects of Therapy Form (HAT) and Satisfaction with Online Treatment (SAT). Programme effectiveness and the effects of carer access on primary and secondary outcome measures will be evaluated on intention-to-treat and per-protocol basis using Linear-Mixed-Models. DISCUSSION This is the first trial comparing the effectiveness and acceptability of iCBT with and without carer access for depression and anxiety among breast cancer survivors. The findings of this study will provide novel data on the acceptability of iCBT programmes for breast cancer survivors and the impact of carer access on them and their carers.
Collapse
Affiliation(s)
- Selin Akkol-Solakoglu
- Aras an Phiarsaigh, School of Psychology, Trinity College Dublin, Dublin, Ireland
- Corresponding author.
| | - David Hevey
- Aras an Phiarsaigh, School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Derek Richards
- Aras an Phiarsaigh, School of Psychology, Trinity College Dublin, Dublin, Ireland
- Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| |
Collapse
|
35
|
Enrique Roig A, Mooney O, Salamanca-Sanabria A, Lee CT, Farrell S, Richards D. Assessing the Efficacy and Acceptability of a Web-Based Intervention for Resilience Among College Students: Pilot Randomized Controlled Trial. JMIR Form Res 2020; 4:e20167. [PMID: 33174530 PMCID: PMC7688384 DOI: 10.2196/20167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/19/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND College students are at elevated risk for developing mental health problems and face specific barriers around accessing evidence-based treatment. Web-based interventions that focus on mental health promotion and strengthening resilience represent one possible solution. Providing support to users has shown to reduce dropout in these interventions. Further research is needed to assess the efficacy and acceptability of these interventions and explore the viability of automating support. OBJECTIVE This study investigated the feasibility of a new web-based resilience program based on positive psychology, provided with human or automated support, in a sample of college students. METHODS A 3-armed closed pilot randomized controlled trial design was used. Participants were randomized to the intervention with human support (n=29), intervention with automated support (n=26), or waiting list (n=28) group. Primary outcomes were resilience and well-being, respectively measured by the Connor-Davidson Resilience Scale and Pemberton Happiness Index. Secondary outcomes included measures of depression and anxiety, self-esteem, and stress. Outcomes were self-assessed through online questionnaires. Intention-to-treat and per-protocol analyses were conducted. RESULTS All participants demonstrated significant improvements in resilience and related outcomes, including an unexpected improvement in the waiting list group. Within- and between-group effect sizes ranged from small to moderate and within-group effects were typically larger for the human than automated support group. A total of 36 participants began the program and completed 46.46% of it on average. Participants were generally satisfied with the program and found it easy to use. CONCLUSIONS Findings support the feasibility of the intervention. Preliminary evidence for the equal benefit of human and automated support needs to be supported by further research with a larger sample. Results of this study will inform the development of a full-scale trial, from which stronger conclusions may be drawn. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN) 11866034; http://www.isrctn.com/ISRCTN11866034. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1016/j.invent.2019.100254.
Collapse
Affiliation(s)
- Angel Enrique Roig
- E-mental Health Research Group, School of Psychology, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Olwyn Mooney
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Alicia Salamanca-Sanabria
- E-mental Health Research Group, School of Psychology, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Future Health Technologies Programme, Campus for Research Excellence and Technological Enterprise, Singapore-ETH Centre, Singapore, Singapore
| | - Chi Tak Lee
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Simon Farrell
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Derek Richards
- E-mental Health Research Group, School of Psychology, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| |
Collapse
|
36
|
Simmonds-Buckley M, Bennion MR, Kellett S, Millings A, Hardy GE, Moore RK. Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis. J Med Internet Res 2020; 22:e17049. [PMID: 33112238 PMCID: PMC7657731 DOI: 10.2196/17049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/18/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development. Objective This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom. Methods Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls. Results A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found. Conclusions Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects. Trial Registration International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184
Collapse
Affiliation(s)
| | - Matthew Russell Bennion
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom.,Department of Computer Science, The University of Sheffield, Sheffield, United Kingdom
| | - Stephen Kellett
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom.,Sheffield Health and Social Care NHS Foundation Trust, Sheffield, United Kingdom
| | - Abigail Millings
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom.,Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, United Kingdom
| | - Gillian E Hardy
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Roger K Moore
- Department of Computer Science, The University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
37
|
Stawarz K, Preist C, Tallon D, Wiles N, Kessler D, Turner K, Shafran R, Coyle D. Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study. JMIR Ment Health 2020; 7:e15972. [PMID: 32880580 PMCID: PMC7499168 DOI: 10.2196/15972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 07/02/2020] [Accepted: 08/10/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists' workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. OBJECTIVE The research aimed to explore patients' and therapists' views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. METHODS We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. RESULTS Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists' workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. CONCLUSIONS To meet clients' and therapists' needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists' workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context.
Collapse
Affiliation(s)
- Katarzyna Stawarz
- School of Computer Science and Informatics, Cardiff University, Cardiff, United Kingdom
| | - Chris Preist
- Department of Computer Science, University of Bristol, Bristol, United Kingdom
| | - Debbie Tallon
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nicola Wiles
- Bristol Medical School, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom
| | - David Kessler
- Bristol Medical School, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, United Kingdom
| | - Katrina Turner
- Bristol Medical School, University of Bristol, Bristol, United Kingdom.,The National Institute for Health Research Applied Research Collaboration West, Bristol, United Kingdom
| | - Roz Shafran
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - David Coyle
- School of Computer Science, University College Dublin, Dublin, Ireland
| |
Collapse
|
38
|
Etzelmueller A, Vis C, Karyotaki E, Baumeister H, Titov N, Berking M, Cuijpers P, Riper H, Ebert DD. Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis. J Med Internet Res 2020; 22:e18100. [PMID: 32865497 PMCID: PMC7490682 DOI: 10.2196/18100] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/06/2020] [Accepted: 06/03/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited. OBJECTIVE This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety. METHODS The acceptability (uptake, participants' characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches. RESULTS A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges' g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants' characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%. CONCLUSIONS This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts.
Collapse
Affiliation(s)
- Anne Etzelmueller
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- GET.ON Institute GmbH, Hamburg, Germany
- Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Mental Health, Amsterdam, Netherlands
| | - Christiaan Vis
- Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Mental Health, Amsterdam, Netherlands
| | - Eirini Karyotaki
- Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam, Amsterdam, Netherlands
- Department of Global Health and Social Medicine, Harvard Medical School, USA, Boston, MA, United States
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Nickolai Titov
- eCentre Clinic Department of Psychology, Macquarie University, Sydney, Australia
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Mental Health, Amsterdam, Netherlands
| | - Heleen Riper
- Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Research Institute, Mental Health, Amsterdam, Netherlands
- Community Mental Health Centre GGZ inGeest, Amsterdam, Netherlands
| | - David Daniel Ebert
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- GET.ON Institute GmbH, Hamburg, Germany
- Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, VU Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
39
|
Cromarty P, Gallagher D, Watson J. Remote delivery of CBT training, clinical supervision and services: in times of crisis or business as usual. COGNITIVE BEHAVIOUR THERAPIST 2020; 13:e33. [PMID: 34191942 PMCID: PMC7468679 DOI: 10.1017/s1754470x20000343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 11/05/2022]
Abstract
The worldwide coronavirus pandemic has forced health services to adapt their delivery to protect the health of all concerned, and avoid service users facing severe disruption. Improving Access to Psychological Therapies (IAPT) services in particular are having to explore remote working methods to continue functioning. Australian IAPT services have utilised remote delivery methods and disruptive technologies at their core from inception. This was to maintain fidelity and clinical governance across vast distances but has allowed training, supervision and service delivery to continue virtually uninterrupted through coronavirus restrictions. On this basis, key recommendations for remote working are outlined. Remote methods are defined as (1) real time delivery, (2) independent delivery and (3) blended delivery. These are applied across three broad areas of remote training, remote clinical supervision and remote service delivery. Recommendations may be of great benefit to IAPT training institutions, clinical supervisors and service providers considering a move towards remote delivery. Challenges, adaptations and examples of applying remote methods are outlined, including case examples of methods applied to low-intensity and high-intensity cognitive behavioural therapy. Remote methods can safeguard service continuity in times of worldwide crisis and can contribute to reducing the impact of increased mental health presentations post-COVID-19. KEY LEARNING AIMS To understand the core areas of remote training, clinical supervision and service delivery.To review and distinguish between three broad methods of remote working.To understand how to plan remote working via key recommendations and case examples.
Collapse
|
40
|
Internet-based cognitive behavioural therapy programme as an intervention for people diagnosed with adult-onset, focal, isolated, idiopathic cervical dystonia: a feasibility study protocol. Pilot Feasibility Stud 2020; 6:100. [PMID: 32685184 PMCID: PMC7362556 DOI: 10.1186/s40814-020-00641-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/30/2020] [Indexed: 11/24/2022] Open
Abstract
Background Dystonia is one of the most common forms of movement disorder, caused by the co-contraction of antagonistic muscles, leading to abnormal postures and considerable disability. Non-motor symptoms, notably psychiatric disorders, are well recognised comorbid features of the disorder. However, there is no standardised model for the management of these symptoms in dystonia, with them frequently going undiagnosed and untreated. An internet-based cognitive behavioural therapy programme may provide a future model of care that also maximises available resources. Methods This study represents a two-armed randomised feasibility trail, aiming to recruit a total of 20 participants with a diagnosis of adult-onset primary focal cervical dystonia. Participants will be recruited from the Global Myoclonus Dystonia Registry and Dystonia Non-Motor Symptom Study (conducted at Cardiff University) based on presence of moderate symptoms of anxiety/depression as indicated by standardised questionnaires. All participants will undergo assessment at baseline, 3 and 6 months, with this including questionnaires for assessment of non-motor symptoms and clinical assessment of motor symptom severity. Participants will be randomised to either the control (n = 10) or treatment (n = 10) groups. The treatment group will be asked to complete one session of the online CBT program a week, for 8 weeks. The primary outcome measure will be the engagement of participants with the programme, with secondary outcomes of non-motor and motor symptom scores. Discussion Promising results have been shown using face-to-face cognitive behavioural therapy to reduce levels of anxiety and depression in individuals with a diagnosis of dystonia. However, no studies to date have sought to determine the feasibility of an internet-delivered cognitive behavioural therapy programme. A number of effective internet-based programmes have been developed that combat anxiety and depression in the general population, suggesting the potential for its effectiveness in cervical dystonia patients. Success with this study would significantly impact the clinical care delivery for patients with cervical dystonia, as well as widening potential access to effective treatment. Trial registration This feasibility trial has been registered with Health and Care Research Wales Research Directory. Trial registration number 44245. Date of registration: 21 November 2019. https://www.healthandcareresearch.gov.wales/research-studies-in-wales/
Collapse
|
41
|
Chien I, Enrique A, Palacios J, Regan T, Keegan D, Carter D, Tschiatschek S, Nori A, Thieme A, Richards D, Doherty G, Belgrave D. A Machine Learning Approach to Understanding Patterns of Engagement With Internet-Delivered Mental Health Interventions. JAMA Netw Open 2020; 3:e2010791. [PMID: 32678450 PMCID: PMC7368176 DOI: 10.1001/jamanetworkopen.2020.10791] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The mechanisms by which engagement with internet-delivered psychological interventions are associated with depression and anxiety symptoms are unclear. OBJECTIVE To identify behavior types based on how people engage with an internet-based cognitive behavioral therapy (iCBT) intervention for symptoms of depression and anxiety. DESIGN, SETTING, AND PARTICIPANTS Deidentified data on 54 604 adult patients assigned to the Space From Depression and Anxiety treatment program from January 31, 2015, to March 31, 2019, were obtained for probabilistic latent variable modeling using machine learning techniques to infer distinct patient subtypes, based on longitudinal heterogeneity of engagement patterns with iCBT. INTERVENTIONS A clinician-supported iCBT-based program that follows clinical guidelines for treating depression and anxiety, delivered on a web 2.0 platform. MAIN OUTCOMES AND MEASURES Log data from user interactions with the iCBT program to inform engagement patterns over time. Clinical outcomes included symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder-7 [GAD-7]); PHQ-9 cut point greater than or equal to 10 and GAD-7 scores greater than or equal to 8 were used to define depression and anxiety. RESULTS Patients spent a mean (SD) of 111.33 (118.92) minutes on the platform and completed 230.60 (241.21) tools. At baseline, mean PHQ-9 score was 12.96 (5.81) and GAD-7 score was 11.85 (5.14). Five subtypes of engagement were identified based on patient interaction with different program sections over 14 weeks: class 1 (low engagers, 19 930 [36.5%]), class 2 (late engagers, 11 674 [21.4%]), class 3 (high engagers with rapid disengagement, 13 936 [25.5%]), class 4 (high engagers with moderate decrease, 3258 [6.0%]), and class 5 (highest engagers, 5799 [10.6%]). Estimated mean decrease (SE) in PHQ-9 score was 6.65 (0.14) for class 3, 5.88 (0.14) for class 5, and 5.39 (0.14) for class 4; class 2 had the lowest rate of decrease at -4.41 (0.13). Compared with PHQ-9 score decrease in class 1, the Cohen d effect size (SE) was -0.46 (0.014) for class 2, -0.46 (0.014) for class 3, -0.61 (0.021) for class 4, and -0.73 (0.018) for class 5. Similar patterns were found across groups for GAD-7. CONCLUSIONS AND RELEVANCE The findings of this study may facilitate tailoring interventions according to specific subtypes of engagement for individuals with depression and anxiety. Informing clinical decision needs of supporters may be a route to successful adoption of machine learning insights, thus improving clinical outcomes overall.
Collapse
Affiliation(s)
- Isabel Chien
- Microsoft Research Cambridge, Cambridge, United Kingdom
| | - Angel Enrique
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Group, School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Jorge Palacios
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Group, School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Tim Regan
- Microsoft Research Cambridge, Cambridge, United Kingdom
| | - Dessie Keegan
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - David Carter
- Microsoft Research Cambridge, Cambridge, United Kingdom
| | | | - Aditya Nori
- Microsoft Research Cambridge, Cambridge, United Kingdom
| | - Anja Thieme
- Microsoft Research Cambridge, Cambridge, United Kingdom
| | - Derek Richards
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Group, School of Psychology, Trinity College Dublin, Dublin, Ireland
| | - Gavin Doherty
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
- School of Computer Science and Statistics, Trinity College Dublin, Dublin, Ireland
| | | |
Collapse
|
42
|
Richards D, Enrique A, Eilert N, Franklin M, Palacios J, Duffy D, Earley C, Chapman J, Jell G, Sollesse S, Timulak L. A pragmatic randomized waitlist-controlled effectiveness and cost-effectiveness trial of digital interventions for depression and anxiety. NPJ Digit Med 2020; 3:85. [PMID: 32566763 PMCID: PMC7295750 DOI: 10.1038/s41746-020-0293-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022] Open
Abstract
Utilization of internet-delivered cognitive behavioural therapy (iCBT) for treating depression and anxiety disorders in stepped-care models, such as the UK's Improving Access to Psychological Therapies (IAPT), is a potential solution for addressing the treatment gap in mental health. We investigated the effectiveness and cost-effectiveness of iCBT when fully integrated within IAPT stepped-care settings. We conducted an 8-week pragmatic randomized controlled trial with a 2:1 (iCBT intervention: waiting-list) allocation, for participants referred to an IAPT Step 2 service with depression and anxiety symptoms (Trial registration: ISRCTN91967124). The primary outcomes measures were PHQ-9 (depressive symptoms) and GAD-7 (anxiety symptoms) and WSAS (functional impairment) as a secondary outcome. The cost-effectiveness analysis was based on EQ-5D-5L (preference-based health status) to elicit the quality-adjust life year (QALY) and a modified-Client Service Receipt Inventory (care resource-use). Diagnostic interviews were administered at baseline and 3 months. Three-hundred and sixty-one participants were randomized (iCBT, 241; waiting-list, 120). Intention-to-treat analyses showed significant interaction effects for the PHQ-9 (b = -2.75, 95% CI -4.00, -1.50) and GAD-7 (b = -2.79, 95% CI -4.00, -1.58) in favour of iCBT at 8-week and further improvements observed up to 12-months. Over 8-weeks the probability of cost-effectiveness was 46.6% if decision makers are willing to pay £30,000 per QALY, increasing to 91.2% when the control-arm's outcomes and costs were extrapolated over 12-months. Results indicate that iCBT for depression and anxiety is effective and potentially cost-effective in the long-term within IAPT. Upscaling the use of iCBT as part of stepped care could help to enhance IAPT outcomes. The pragmatic trial design supports the ecological validity of the findings.
Collapse
Affiliation(s)
- Derek Richards
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Angel Enrique
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Nora Eilert
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | | | - Jorge Palacios
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Daniel Duffy
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Caroline Earley
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Judith Chapman
- Berkshire Healthcare NHS Foundation Trust, London, Berkshire, England
| | - Grace Jell
- Berkshire Healthcare NHS Foundation Trust, London, Berkshire, England
| | - Sarah Sollesse
- Berkshire Healthcare NHS Foundation Trust, London, Berkshire, England
| | - Ladislav Timulak
- Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| |
Collapse
|
43
|
Knapstad M, Sæther SMM, Hensing G, Smith ORF. Prompt Mental Health Care (PMHC): work participation and functional status at 12 months post-treatment. BMC Health Serv Res 2020; 20:85. [PMID: 32019521 PMCID: PMC7001227 DOI: 10.1186/s12913-020-4932-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 01/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anxiety and depression are associated with substantial functional impairment. Prompt Mental Health Care (PMHC), the Norwegian adaptation of IAPT is currently piloted across Norway, as a means to improve access to evidence-based care for adults with anxiety disorders (including subthreshold cases) and minor to moderate depression. The aims of the current paper were to examine the change in work status and functional status from pre- to post-treatment and 12 months post-treatment among clients at the first 12 PMHC pilot sites, and whether degree of change differed across sociodemographic characteristics. METHODS A prospective cohort design was used, including working age clients receiving treatment between October 2014 and December 2016 (n = 1446, participation rate = 61%). Work status and functional status were self-reported, the latter by the Work and Social Adjustment Scale (WSAS). Changes in work status and WSAS score were examined through multilevel models based on maximum likelihood estimation. Likelihood ratio tests were performed to determine whether the interaction between time and the respective background variables were statistically significant. RESULTS A substantial increase in regular work participation was observed from pre- to post-treatment, which further had increased at 12 months post-treatment. The increase was driven by a corresponding reduction in proportion of clients working and receiving benefits (OR 0.38 [0.29-0.50] baseline to final treatment, OR = 0.19 [0.12-0.32] final treatment to 12-months post-treatment), while no statistically significant change was observed in proportion out of work. Large improvement (ES = - 0.89) in WSAS score was observed from pre- to post treatment. WSAS score at 12 months post-treatment remained at the post-treatment level. CONCLUSIONS Previous research has shown substantial symptom improvement among clients receiving treatment in PMHC. The current findings indicate that PMHC might also be able to aid adults struggling with mild to moderate anxiety and depression in returning to usual level of functioning. The degree to which the observed improvements are attributable to the treatment need nonetheless to be confirmed in a trial including a control group and with more complete follow-up data from registries.
Collapse
Affiliation(s)
- Marit Knapstad
- Department of Clinical Psychology, University of Bergen, P.B. 7807, N-5020 Bergen, Norway
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, N-5015 Bergen, Norway
| | | | - Gunnel Hensing
- School of Public Health and Community Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Otto Robert Frans Smith
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, N-5015 Bergen, Norway
| |
Collapse
|
44
|
Salamanca-Sanabria A, Richards D, Timulak L, Connell S, Mojica Perilla M, Parra-Villa Y, Castro-Camacho L. A Culturally Adapted Cognitive Behavioral Internet-Delivered Intervention for Depressive Symptoms: Randomized Controlled Trial. JMIR Ment Health 2020; 7:e13392. [PMID: 32003749 PMCID: PMC7055858 DOI: 10.2196/13392] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/24/2019] [Accepted: 08/07/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Internet-delivered treatments for depressive symptoms have proved to be successful in high-income Western countries. There may be potential for implementing such treatments in low- and middle-income countries such as Colombia, where access to mental health services is limited. OBJECTIVE The objective of this study was to assess the efficacy of a culturally adapted cognitive behavioral internet-delivered treatment for college students with depressive symptoms in Colombia. METHODS This was a randomized controlled trial with a 3-month follow-up. The program comprised seven modules. A total of 214 Colombian college students were recruited. They were assessed and randomly assigned to either the treatment group (n=107) or a waiting list (WL) control group (n=107). Participants received weekly support from a trained supporter. The primary outcome was symptoms of depression, as measured by the Patient Health Questionnaire - 9, and the secondary outcomes were anxiety symptoms assessed by the Generalized Anxiety Disorder questionnaire - 7. Other measures, including satisfaction with treatment, were evaluated after 7 weeks. RESULTS Research attrition and treatment dropouts were high in this study. On average, 7.6 sessions were completed per user. The mean time spent on the program was 3 hours and 18 min. The linear mixed model (LMM) showed significant effects after treatment (t197.54=-5.189; P<.001) for the treatment group, and these effects were maintained at the 3-month follow-up (t39.62=4.668; P<.001). Within-group results for the treatment group yielded a large effect size post treatment (d=1.44; P<.001), and this was maintained at the 3-month follow-up (d=1.81; P<.001). In addition, the LMM showed significant differences between the groups (t197.54=-5.189; P<.001). The results showed a large effect size between the groups (d=0.91; P<.001). In the treatment group, 76.0% (16/107) achieved a reliable change, compared with 32.0% (17/107) in the WL control group. The difference between groups was statistically significant (X22=10.5; P=.001). CONCLUSIONS This study was the first contribution to investigating the potential impact of a culturally adapted internet-delivered treatment on depressive symptoms for college students as compared with a WL control group in South America. Future research should focus on identifying variables associated both with premature dropout and treatment withdrawal at follow-up. TRIAL REGISTRATION ClinicalTrials.gov NCT03062215; https://clinicaltrials.gov/ct2/show/NCT03062215.
Collapse
Affiliation(s)
- Alicia Salamanca-Sanabria
- Trinity College Dublin, School of Psychology, E-mental Health Research Group, Dublin, Ireland.,SilverCloud Health, Clinical Research & Innovation, Dublin, Ireland
| | - Derek Richards
- Trinity College Dublin, School of Psychology, E-mental Health Research Group, Dublin, Ireland.,SilverCloud Health, Clinical Research & Innovation, Dublin, Ireland
| | - Ladislav Timulak
- Trinity College Dublin, School of Psychology, E-mental Health Research Group, Dublin, Ireland
| | - Sarah Connell
- SilverCloud Health, Clinical Research & Innovation, Dublin, Ireland
| | | | - Yamilena Parra-Villa
- Universidad Autonoma de Bucaramanga, School of Psychology, Bucaramanga, Colombia
| | | |
Collapse
|
45
|
Burger F, Neerincx MA, Brinkman WP. Technological State of the Art of Electronic Mental Health Interventions for Major Depressive Disorder: Systematic Literature Review. J Med Internet Res 2020; 22:e12599. [PMID: 31958063 PMCID: PMC6997926 DOI: 10.2196/12599] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 08/16/2019] [Accepted: 10/31/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Electronic mental (e-mental) health care for depression aims to overcome barriers to and limitations of face-to-face treatment. Owing to the high and growing demand for mental health care, a large number of such information and communication technology systems have been developed in recent years. Consequently, a diverse system landscape formed. OBJECTIVE This literature review aims to give an overview of this landscape of e-mental health systems for the prevention and treatment of major depressive disorder, focusing on three main research questions: (1) What types of systems exist? (2) How technologically advanced are these systems? (3) How has the system landscape evolved between 2000 and 2017? METHODS Publications eligible for inclusion described e-mental health software for the prevention or treatment of major depressive disorder. Additionally, the software had to have been evaluated with end users and developed since 2000. After screening, 270 records remained for inclusion. We constructed a taxonomy concerning software systems, their functions, how technologized these were in their realization, and how systems were evaluated, and then, we extracted this information from the included records. We define here as functions any component of the system that delivers either treatment or adherence support to the user. For this coding process, an elaborate classification hierarchy for functions was developed yielding a total of 133 systems with 2163 functions. The systems and their functions were analyzed quantitatively, with a focus on technological realization. RESULTS There are various types of systems. However, most are delivered on the World Wide Web (76%), and most implement cognitive behavioral therapy techniques (85%). In terms of content, systems contain twice as many treatment functions as adherence support functions, on average. Furthermore, autonomous systems, those not including human guidance, are equally as technologized and have one-third less functions than guided ones. Therefore, lack of guidance is neither compensated with additional functions nor compensated by technologizing functions to a greater degree. Although several high-tech solutions could be found, the average system falls between a purely informational system and one that allows for data entry but without automatically processing these data. Moreover, no clear increase in the technological capabilities of systems showed in the field, between 2000 and 2017, despite a marked growth in system quantity. Finally, more sophisticated systems were evaluated less often in comparative trials than less sophisticated ones (OR 0.59). CONCLUSIONS The findings indicate that when developers create systems, there is a greater focus on implementing therapeutic treatment than adherence support. Although the field is very active, as evidenced by the growing number of systems developed per year, the technological possibilities explored are limited. In addition to allowing developers to compare their system with others, we anticipate that this review will help researchers identify opportunities in the field.
Collapse
Affiliation(s)
| | - Mark A Neerincx
- Delft University of Technology, Delft, Netherlands.,Nederlandse Organisatie voor Toegepast Natuurwetenschappelijk Onderzoek (TNO), Department of Perceptual and Cognitive Systems, Soesterberg, Netherlands
| | | |
Collapse
|
46
|
Duffy D, Enrique A, Connell S, Connolly C, Richards D. Internet-Delivered Cognitive Behavior Therapy as a Prequel to Face-To-Face Therapy for Depression and Anxiety: A Naturalistic Observation. Front Psychiatry 2020; 10:902. [PMID: 31998149 PMCID: PMC6962244 DOI: 10.3389/fpsyt.2019.00902] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 11/14/2019] [Indexed: 01/16/2023] Open
Abstract
Background: The UK's Improving Access to Psychological Therapies (IAPT) program is a stepped-care model treating individuals with depression and anxiety disorders. Internet-delivered cognitive behavioral therapy (iCBT) is routinely offered to individuals with mild to moderate symptoms, but its applicability to individuals with severe clinical symptoms and requiring a high-intensity intervention is relatively unknown. The current study sought to investigate the potential impacts of using iCBT as a prequel for patients requiring high-intensity treatment (HIT; face-to-face) for depression and anxiety in IAPT. Methods: The study utilized an open study design. One hundred and twenty-four participants who were on a waiting list for high-intensity, face-to-face psychological treatment were offered iCBT. Psychometric data on symptoms of depression, anxiety, and functioning were collected from participants before starting and on finishing iCBT and at the point of service exit. Therapeutic alliance data were collected from patients and clinicians during treatment. Patient pathway data, such as number of treatment sessions and time in treatment, was also collected and incorporated into the analysis. Results: Significant reductions across primary outcome measures of depression and anxiety, as well as improved functioning, were observed from baseline to iCBT treatment exit, and from iCBT exit to service exit. Analysis of the therapeutic alliance data for patients and clinicians illustrated differences in outcome for those who dropped out and those who completed treatment. Discussion: This study illustrates the potential for using iCBT as a prequel to high-intensity therapy for depression and anxiety disorders and is the first of its kind to do so within IAPT stepped care. The results show that iCBT is a valuable option reducing waiting times and enhancing clinical efficiency. The study contributes to the well-established evidence on online psychological treatments worldwide, but further clinical and service development research is necessary to scale these treatments appropriately.
Collapse
Affiliation(s)
- Daniel Duffy
- Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Research Group, School of Psychology, Trinity College, Dublin, Ireland
| | - Angel Enrique
- Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Research Group, School of Psychology, Trinity College, Dublin, Ireland
| | - Sarah Connell
- Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| | - Conor Connolly
- Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
| | - Derek Richards
- Clinical Research and Innovation, SilverCloud Health, Dublin, Ireland
- E-Mental Health Research Group, School of Psychology, Trinity College, Dublin, Ireland
| |
Collapse
|
47
|
Stavropoulos V, Cokorilo S, Kambouropoulos A, Collard J, Gomez R. Cognitive Behavioral Therapy Online for Adult Depression: A 10 Year Systematic Literature Review. CURRENT PSYCHIATRY RESEARCH AND REVIEWS 2019. [DOI: 10.2174/1573400515666190628125914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background:
Acceptance, adherence and efficacy aspects of Cognitive Behavioural
Therapy (CBT) online have invited significant interest, especially in the context of “stepped care”
models, which advocate progressive stages of intervention in addressing depression. Objectives: The
current work aspires to comprehensively identify critical factors linked to the applicability of online
CBT, in order to inform clinical practices and future research targeting depressive behaviors in early
and middle adulthood.
Methods:
To serve these goals: a) the PRISMA systematic literature perspective is followed; b) a
systematic search of online databases between 2008-2018 was undertaken and; c) a compositehybrid
model, resulting from the integration of broadly adopted conceptualizations from the areas of
psychological treatment and internet use behaviors, was combined with an interpretative phenomenological
analysis perspective to organize the findings.
Results:
In total, 28 studies were included in the present review. Factors defining the efficacy, adherence
and acceptability of online CBT targeting depression (during early and middle adulthood)
were classified into parameters related to the individual receiver, the context and the CBT activities
involved.
Conclusion:
Despite the cautiousness warranted by the limitations, as well as the diverge methodology of
the reviewed studies, findings appear to favour the provision of brief, therapist supported, online
CBT interventions, especially in addressing moderate depression during early and middle adulthood.
Collapse
Affiliation(s)
| | - Sandra Cokorilo
- The Cairnmillar Institute, School of Psychology, Melbourne, Australia
| | | | - James Collard
- The Cairnmillar Institute, School of Psychology, Melbourne, Australia
| | - Rapson Gomez
- Federation University, Mount Helen, VIC 3350, Australia
| |
Collapse
|
48
|
Enrique A, Palacios JE, Ryan H, Richards D. Exploring the Relationship Between Usage and Outcomes of an Internet-Based Intervention for Individuals With Depressive Symptoms: Secondary Analysis of Data From a Randomized Controlled Trial. J Med Internet Res 2019; 21:e12775. [PMID: 31373272 PMCID: PMC6694731 DOI: 10.2196/12775] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 06/04/2019] [Accepted: 06/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background Internet interventions can easily generate objective data about program usage. Increasingly, more studies explore the relationship between usage and outcomes, but they often report different metrics of use, and the findings are mixed. Thus, current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change. Objective This study aimed to explore the relationship between several usage metrics and outcomes of an internet-based intervention for depression. Methods This is a secondary analysis of data from a randomized controlled trial that examined the efficacy of an internet-based cognitive behavioral therapy for depression (Space from Depression) in an adult community sample. All participants who enrolled in the intervention, regardless of meeting the inclusion criteria, were included in this study. Space from Depression is a 7-module supported intervention, delivered over a period of 8 weeks. Different usage metrics (ie, time spent, modules and activities completed, and percentage of program completion) were automatically collected by the platform, and composite variables from these (eg, activities per session) were computed. A breakdown of the usage metrics was obtained by weeks. For the analysis, the sample was divided into those who obtained a reliable change (RC)—and those who did not. Results Data from 216 users who completed pre- and posttreatment outcomes were included in the analyses. A total of 89 participants obtained an RC, and 127 participants did not obtain an RC. Those in the RC group significantly spent more time, had more log-ins, used more tools, viewed a higher percentage of the program, and got more reviews from their supporter compared with those who did not obtain an RC. Differences between groups in usage were observed from the first week in advance across the different metrics, although they vanished over time. In the RC group, the usage was higher during the first 4 weeks, and then a significant decrease was observed. Our results showed that specific levels of platform usage, 7 hours total time spent, 15 sessions, 30 tools used, and 50% of program completion, were associated with RC. Conclusions Overall, the results showed that those individuals who obtained an RC after the intervention had higher levels of exposure to the platform. The usage during the first half of the intervention was higher, and differences between groups were observed from the first week. This study also showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence. These results will help to better understand how to use internet-based interventions and what optimal level of engagement can most affect outcomes. Trial Registration ISRCTN Registry ISRCTN03704676; http://www.isrctn.com/ISRCTN03704676 International Registered Report Identifier (IRRID) RR2-10.1186/1471-244X-14-147
Collapse
Affiliation(s)
- Angel Enrique
- E-mental Health Research Group, School of Psychology, Dublin, Ireland.,Clinical Research & Innovation, Silvercloud Health Ltd, Dublin, Ireland
| | - Jorge E Palacios
- E-mental Health Research Group, School of Psychology, Dublin, Ireland.,Clinical Research & Innovation, Silvercloud Health Ltd, Dublin, Ireland
| | - Holly Ryan
- Clinical Research & Innovation, Silvercloud Health Ltd, Dublin, Ireland
| | - Derek Richards
- E-mental Health Research Group, School of Psychology, Dublin, Ireland.,Clinical Research & Innovation, Silvercloud Health Ltd, Dublin, Ireland
| |
Collapse
|
49
|
Salamanca-Sanabria A, Richards D, Timulak L. Adapting an internet-delivered intervention for depression for a Colombian college student population: An illustration of an integrative empirical approach. Internet Interv 2019; 15:76-86. [PMID: 30740313 PMCID: PMC6356089 DOI: 10.1016/j.invent.2018.11.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/15/2018] [Accepted: 11/05/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Culturally adapted psychotherapy (CAP) studies are limited and until now there are few published examples that illustrate the process of cultural adaptation with internet-delivered treatments. AIM This paper aims to illustrate an integrative approach to the cultural adaptation of an evidence-based internet-delivered cognitive-behavioural therapy intervention for depression (Space from Depression programme). METHOD Mixed method approach utilising quantitative and qualitative methods to assist in the cultural adaptation of the Space from Depression programme was used. The adaptation involved a framework for cultural sensitivity (CSF), alongside an ecological validity framework (EVF) and principles from cross-cultural assessment research. The method included the development of a theory-informed measure, the Cultural Relevance Questionnaire (CRQ), designed specifically for this research. RESULTS The adaptation included an establishment of CSF, which included the incorporation of Colombian cultural expressions. College students' (n = 5) and experts' (n = 7) evaluated the EVF based on cross-cultural assessment principles of a preliminary adapted version through the CRQ, showing reliability in the sample (Cronbach's Alpha 0.744). Qualitative analysis supported the culturally sensitive changes or incorporations made to the programme, such as: personal stories and textual translations from English and these were considered ecologically valid and representative. CONCLUSIONS The research provided support for the idea that CAP can be conducted systematically for internet-delivered interventions.
Collapse
Affiliation(s)
- Alicia Salamanca-Sanabria
- E-mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland,Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland,Corresponding author at: E-mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland.
| | - Derek Richards
- E-mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland,Clinical Research & Innovation, SilverCloud Health, Dublin, Ireland
| | - Ladislav Timulak
- E-mental Health Research Group, School of Psychology, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
50
|
Birk MV, Mandryk RL. Improving the Efficacy of Cognitive Training for Digital Mental Health Interventions Through Avatar Customization: Crowdsourced Quasi-Experimental Study. J Med Internet Res 2019; 21:e10133. [PMID: 30622095 PMCID: PMC6329434 DOI: 10.2196/10133] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/17/2018] [Accepted: 09/06/2018] [Indexed: 01/17/2023] Open
Abstract
Background The success of internet-based mental health interventions in practice—that is, in the wild—depends on the uptake and retention of the application and the user’s focused attention in the moment of use. Incorporating game-based motivational design into digital interventions delivered in the wild has been shown to increase uptake and retention in internet-based training; however, there are outstanding questions about the potential of game-based motivational strategies to increase engagement with a task in the moment of use and the effect on intervention efficacy. Objective Designers of internet-based interventions need to know whether game-based motivational design strategies can increase in-the-moment engagement and thus improve digital interventions. The aim of this study was to investigate the effects of 1 motivational design strategy (avatar customization) in an example mental health intervention (computerized cognitive training for attention bias modification). Methods We assigned 317 participants to either a customized avatar or an assigned avatar condition. After measuring state anxiety (State-Trait Anxiety Inventory), we randomly assigned half of the participants in each condition to either an attentional retraining condition (Attention Bias Modification Training) or a control condition. After training, participants were exposed to a negative mood induction using images with strong negative valance (International Affective Picture System), after which we measured state anxiety again. Results Avatar customization decreased posttraining state anxiety when controlling for baseline state anxiety for those in the attentional retraining condition; however, those who did not train experienced decreased resilience to the negative mood induction (F1,252=6.86, P=.009, ηp2=.027). This interaction effect suggests that customization increased task engagement with the intervention in the moment of use. Avatar customization also increased avatar identification (F5,252=12.46, P<.001, R2=.23), regardless of condition (F1,252=.79, P=.38). Avatar identification reduced anxiety after the negative mood induction for participants who underwent training but increased poststimulus anxiety for participants who did not undergo training, further suggesting that customization increases engagement in the task (F1,252=6.19, P=.01). The beneficial effect of avatar customization on training was driven by participants who were low in their basic satisfaction of relatedness (F10,248=18.5, P<.001, R2=.43), which is important because these are the participants who are most likely in need of digital interventions for mental health. Conclusions Our results suggest that applying motivational design—specifically avatar customization—is a viable strategy to increase engagement and subsequently training efficacy in a computerized cognitive task.
Collapse
Affiliation(s)
- Max Valentin Birk
- University of Saskatchewan, Department of Computer Science, Saskatoon, SK, Canada
| | - Regan Lee Mandryk
- University of Saskatchewan, Department of Computer Science, Saskatoon, SK, Canada
| |
Collapse
|