Up-scaling clinician assisted internet cognitive behavioural therapy (iCBT) for depression: A model for dissemination into primary care

Mental health and cognition in relation to adherence to antiretroviral therapy among people living with HIV in Kazakhstan: a cross-sectional study

INTRODUCTION

There is a research gap in how mental health and cognition are associated with antiretroviral treatment (ART) adherence among people living with HIV (PLWH) in Kazakhstan.

METHODS

We randomly selected and enrolled 230 PLWH from the Almaty City AIDS Center registry (June-November 2019) into a cross-sectional study. We examined associations between self-reported ART adherence for the last 1 and 2 weeks; the Adherence Self-Efficacy Scale (ASES) and symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder tool [GAD-7]), post-traumatic stress disorder (PTSD Checklist [PTSD]); cognitive function (PROMIS v2.0 Adult Cognitive Function 8a short form) and forgetfulness (Forgetfulness Assessment Inventory). We used cut points of ≥5 for at least mild and ≥10 for at least moderate symptom severity for PHQ-9 and GAD-7 and of ≥44 for PTSD. Logistic and linear regression analyses were used.

RESULTS

Participants' median age was 40.0 (IQR: 34-47) with 40.9% (n = 94) of females in the sample. Those who missed at least one pill for the last 2 weeks had higher odds of reporting at least mild depression (aOR = 3.34, 95% CI: 1.22-9.11, p < 0.05); mild anxiety (aOR = 3.27, 95% CI: 1.20-8.92, p < 0.05); and PTSD (aOR = 4.04, 95% CI: 1.15-14.21, p < 0.05) symptoms. Participants who missed at least one pill for the last week had higher odds of at least mild depression (aOR = 7.74, 95% CI: 1.31-45.7, p < 0.05), moderate anxiety (aOR = 21.33, 95% CI: 3.24-140.33, p < 0.005) and PTSD (aOR = 13.81, 95% CI: 2.36-80.84, p < 0.005) symptoms. Participants with better cognitive function had lower odds of non-adherence over the last week (aOR = 0.88, 95% CI: 0.81-0.96, p < 0.005) and higher ASES scores (β = 0.26, 95% CI: 0.13-0.40, p < 0.005). Poor memory was associated with higher odds of non-adherence over the last week (aOR = 4.64, 95% CI: 1.76-12.24, p < 0.005) and lower ASES score (β = -0.31, 95% CI: -0.45 to 0.16, p < 0.005). Those who had at least mild depression (β = -0.21, 95% CI: -0.35 to -0.07, p < 0.005); moderate anxiety (β = -0.21, 95% CI: -0.34 to -0.07, p < 0.005) and PTSD (β = -0.19, 95% CI: -0.33 to -0.05, p < 0.005) symptoms had lower ASES scores.

CONCLUSIONS

Depression, anxiety and PTSD symptoms, poorer cognition, and forgetfulness were associated with poorer ART adherence and worse adherence self-efficacy. It is crucial to assess and treat mental illness and provide support for PLWH with worsened cognition to enhance ART adherence.

Positive psychotherapy and cognitive behavioral therapy in anxiety patients - A study protocol for a randomized control trial in an online group setting

BACKGROUND

Anxiety disorders are common and debilitating which is why treatment is so important. According to the guidelines, Cognitive Behavioral Therapy (CBT) has the highest level of effectiveness among psychotherapeutic treatments and is the recommended procedure. However, not everyone responds well or at all to CBT which makes a wider range of therapy options valuable. Positive Psychotherapy (PPT) comes to mind as an alternative with its strength-based approach focusing on enhancing well-being and life satisfaction. Additionally, it has not yet been extensively studied how the processes that occur during treatment sessions and between treatment sessions effect treatment outcome. Thus, to lessen the lack of evidence regarding the efficacy of PPT as an anxiety treatment the planned study examines and compares the effectiveness of CBT and PPT as well as the effect of intrasession and intersession processes of the two therapy approaches.

METHOD

The study is in the planning stage and consists of an efficacy and a process study. The efficacy study is a randomized controlled comparative study of patients with anxiety disorders (generalized anxiety disorder and/or panic disorder with or without agoraphobia) with two active treatment conditions (PPT and CBT) and a control group (CG; positive psychotherapy with minimal therapeutic supervision) in an online group setting. There are three measurement time points: before treatment begins (T0), at the end of the ten-week treatment (T1), and a follow-up after three months (T2). The aim of the study is to evaluate the efficacy of PPT and CBT in the treatment of anxiety disorders, and to compare the efficacy of online-based PPT with minimal therapeutic supervision and online-based PPT with intensive therapeutic supervision in the treatment of anxiety disorders. The process study will be used to evaluate both the intrasession processes and the intersession processes of the therapy in the two intervention groups. In addition, the process variables that predict the success of the therapy and the extent to which PPT and CBT differ in the therapy processes will be tested. The study is registered at the German Clinical Trial Register (№ DRKS00027521).

DISCUSSION

To our knowledge, this is the first randomized controlled comparative study to examine the effectiveness of CBT and PPT for anxiety disorders in an online group setting.

Implementing internet-delivered cognitive behavioral therapy in healthcare services: a qualitative exploration of stakeholder experience

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.

Using Artificial Intelligence to Enhance Ongoing Psychological Interventions for Emotional Problems in Real- or Close to Real-Time: A Systematic Review

Emotional disorders are the most common mental disorders globally. Psychological treatments have been found to be useful for a significant number of cases, but up to 40% of patients do not respond to psychotherapy as expected. Artificial intelligence (AI) methods might enhance psychotherapy by providing therapists and patients with real- or close to real-time recommendations according to the patient's response to treatment. The goal of this investigation is to systematically review the evidence on the use of AI-based methods to enhance outcomes in psychological interventions in real-time or close to real-time. The search included studies indexed in the electronic databases Scopus, Pubmed, Web of Science, and Cochrane Library. The terms used for the electronic search included variations of the words "psychotherapy", "artificial intelligence", and "emotional disorders". From the 85 full texts assessed, only 10 studies met our eligibility criteria. In these, the most frequently used AI technique was conversational AI agents, which are chatbots based on software that can be accessed online with a computer or a smartphone. Overall, the reviewed investigations indicated significant positive consequences of using AI to enhance psychotherapy and reduce clinical symptomatology. Additionally, most studies reported high satisfaction, engagement, and retention rates when implementing AI to enhance psychotherapy in real- or close to real-time. Despite the potential of AI to make interventions more flexible and tailored to patients' needs, more methodologically robust studies are needed.

Ecological momentary intervention to enhance emotion regulation in healthcare workers via smartphone: a randomized controlled trial protocol

BACKGROUND

CUIDA-TE is an APP that offers transdiagnostic cognitive behavioral therapy focused on enhancing emotion regulation. As a novelty, it incorporates ecological momentary interventions (EMI), which can provide psychological support in real time, when suffering arises. The main goal of the study is to evaluate the efficacy of CUIDA-TE to improve emotion regulation in healthcare workers, a population that has been particularly emotionally impacted by the COVID-19 pandemic.

METHODS

In this three-arm, randomized controlled trial (RCT) the study sample will be composed of a minimum of 174 healthcare workers. They will be randomly assigned to a 2-month EMI group (CUIDA-TE APP, n ≥ 58), a 2-month ecological momentary assessment (EMA) only group (MONITOR EMOCIONAL APP, n ≥ 58), or a wait-list control group (no daily monitoring nor intervention, n ≥ 58). CUIDA-TE will provide EMI if EMA reveals emotional problems, poor sleep quality/quantity, burnout, stress, or low perceived self-efficacy when regulating emotions. Depression will be the primary outcome. Secondary outcomes will include emotion regulation, quality of life, and resilience. Treatment acceptance and usability will also be measured. Primary and secondary outcomes will be obtained at pre- and post-intervention measurements, and at the 3-month follow-up for all groups.

DISCUSSION

To our knowledge, this is the first RCT that evaluates the efficacy of an APP-based EMI to improve emotion regulation skills in healthcare workers. This type of intervention might ultimately help disseminate treatments and reach a larger number of individuals than traditional face-to-face individual therapies.

TRIAL REGISTRATION

ClinicalTrial.gov : NCT04958941 Registered 7 Jun 2021.

STUDY STATUS

Participant recruitment has not started.

Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster

BACKGROUND

Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND.

OBJECTIVE

This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT).

METHODS

In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up.

RESULTS

Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups.

CONCLUSIONS

In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364683&isReview=true.

Beyond Efficacy and Effectiveness: Clinical Efficiency Is Necessary for Dissemination

Nearly all patients interact with critical gatekeepers-insurance companies or centralized healthcare systems. For mental health dissemination efforts to be successful, these gatekeepers must refer patients to evidence-based care. To make these referral decisions, they require evidence about the amount of resources expended to achieve therapeutic gains. Without this information, a bottleneck to widespread dissemination of evidence-based care will remain. To address this need for information, we introduce a new perspective, clinical efficiency. This approach directly ties resource usage to clinical outcomes. We highlight how cost-effectiveness approaches and other strategies can address clinical efficiency, and we also introduce a related new metric, the incremental time efficiency ratio (ITER). The ITER is particularly useful for quantifying the benefits of low-intensity and concentrated interventions, as well as stepped-care approaches. Given that stakeholders are increasingly requiring information on resource utilization, the ITER is a metric that can be estimated for past and future clinical trials. As a result, the ITER can allow researchers to better communicate desirable aspects of treatment, and an increased focus on clinical efficiency can improve our ability to deliver high-quality treatment to more patients in need.

Toward proficiency in telebehavioral health: applying interprofessional competencies in couple and family therapy

During the coronavirus pandemic, many behavioral health professionals providing psychotherapeutic services, including couple/marriage and family therapists (C/MFTs), quickly changed from providing in-person services to telebehavioral health (TBH) services, with specific reliance on teleconferencing. Many therapists were thrust into telehealth with minimal or no prior telebehavioral health experience, education, or training. Although TBH services have been shown to be effective and efficient with mental health and substance abuse problems, the teaching and learning of telebehavioral competencies have generally not been included in the formal education and training received by C/MFTs. This article presents an existing interprofessional telebehavioral health competencies framework not before published in C/MFT journals. This article will also demonstrate how those competencies are applicable to the education, training, and practice of telebehavioral health by C/MFTs. Implications for educational, service, and regulatory organizations are presented.

Video-Counseling Intervention to Address HIV Care Engagement, Mental Health, and Substance Use Challenges: A Pilot Randomized Clinical Trial for Youth and Young Adults Living with HIV

Background: Substance use and mental health are two barriers to engagement in care and antiretroviral therapy (ART) adherence among youth and young adults living with HIV (YLWH). The consequences of suboptimal adherence in YLWH are increased risk of HIV transmission and a future generation of immunodeficient adults with drug-resistant virus. Methods: The Youth to Telehealth and Texting for Engagement in Care (Y2TEC) study was a pilot randomized crossover trial that examined the feasibility and acceptability of a novel video-counseling series and accompanying text messages aimed at mental health, substance use, and HIV care engagement for YLWH. The intervention consisted of twelve 20-30-min weekly video-counseling sessions focused on identifying and addressing barriers to HIV care, mental health, and substance use challenges. Participants completed quantitative surveys at baseline, 4 months, and 8 months. Feasibility and acceptability were evaluated using prespecified benchmarks. Results: Fifty YLWH aged 18-29 years living in the San Francisco Bay Area were enrolled. Eighty-six percent and 75% of participants were retained at 4 and 8 months, respectively. A total of 455 (76%) video-counseling sessions were completed. In 82% of sessions, participants responded that they strongly agreed/agreed with this statement: "I felt heard, understood, and respected by the counselor." In 81% of sessions, participants responded that they strongly agreed/agreed with this statement: "Overall, today's session was right for me." At baseline, among participants reporting mental health challenges, only 10% noted having ever received mental health services, and among those who reported substance use challenges, ∼19% reported ever receiving substance use services. After 4 months of the Y2TEC intervention, participants reported slightly higher ART adherence and HIV knowledge, decreased depression and anxiety, and reduced stigma related to mental health and substance use. Conclusions: The Y2TEC intervention using video-counseling and text messaging was feasible and acceptable for YLWH. ClinicalTrials.gov ID: NCT03681145.

A Low-Intensity Internet-Based Intervention Focused on the Promotion of Positive Affect for the Treatment of Depression in Spanish Primary Care: Secondary Analysis of a Randomized Controlled Trial

Background: A large number of low-intensity Internet-based interventions (IBIs) for the treatment of depression have emerged in Primary Care; most of them focused on decreasing negative emotions. However, recent studies have highlighted the importance of addressing positive affect (PA) as well. This study is a secondary analysis of a randomized control trial. We examine the role of an IBI focused on promoting PA in patients with depression in Primary Care (PC). The specific objectives were to explore the profile of the patients who benefit the most and to analyze the change mechanisms that predict a significantly greater improvement in positive functioning measures. Methods: 56 patients were included. Measures of depression, affect, well-being, health-related quality of life, and health status were administered. Results: Participants who benefited the most were those who had lower incomes and education levels and worse mental health scores and well-being at baseline (7.9%-39.5% of explained variance). Improvements in depression severity and PA were significant predictors of long-term change in well-being, F (3,55) = 17.78, p < 0.001, R2 = 47.8%. Conclusions: This study highlights the importance of implementing IBIs in PC and the relevance of PA as a key target in Major Depressive Disorder treatment.

Primary Care Peer-Supported Internet-Mediated Psychological Treatment for Adults With Anxiety Disorders: Mixed Methods Study

Background

The effect of internet-delivered cognitive behavioral therapy (iCBT) on anxiety in adults is well-known. However, patient dropouts and poor adherence to treatment are common. Feelings of belonging and empowerment from the treatment might be key to the completion of iCBT. Peer support workers are people with a personal experience of mental health problems, trained to provide professional support to people who require mental health care.

Objective

This study aims to assess patient experiences; the feasibility, safety, and acceptability; and preliminary effectiveness on anxiety and depression, empowerment, and adherence to treatment in an 8-week peer-supported iCBT program for patients with anxiety disorders treated in primary care.

Methods

This was a single-arm mixed methods feasibility study. Participants were patients referred to a central unit for iCBT in primary care. Quantitative data were collected pre-, post-, and 3 months postintervention. Qualitative data were collected through semistructured interviews.

Results

A total of 9 participants completed the quantitative outcome assessment. Statistically significant improvements were observed in perceived empowerment at a 3-month follow-up, and significant decreases in anxiety, depression, and psychological distress at the end of the treatment were maintained at a 3-month follow-up. In total, 8 of the 9 patients showed improvement in the severity of their symptoms of anxiety. Adherence to treatment was good among the participants. No serious adverse events were reported. Eight participants were enrolled in the qualitative analysis. The qualitative results showed 3 main themes: (1) real contact in an online world, (2) empowering experiences, and (3) being behind the wheel. Qualitative results largely emphasized the personal relationship and supported the acceptability of adding peer support to iCBT.

Conclusions

Peer support in digital treatment seems to be a safe and acceptable intervention. The preliminary results suggest the effectiveness of peer support on patient empowerment, anxiety, depression, psychological distress, and adherence to treatment. The results indicate the need for future studies to evaluate the effect of adding peer support to iCBT in larger randomized controlled trials.

Implementing Web-Based Therapy in Routine Mental Health Care: Systematic Review of Health Professionals' Perspectives

BACKGROUND

Web-based therapies hold great promise to increase accessibility and reduce costs of delivering mental health care; however, uptake in routine settings has been low.

OBJECTIVE

Our objective in this review was to summarize what is known about health care professionals' perceptions of the barriers to and facilitators of the implementation of web-based psychological treatments in routine care of adults in health care settings.

METHODS

We searched 5 major databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library) for qualitative, quantitative, or mixed-methods studies exploring health professionals' views on computer- or internet-based psychological treatment programs. We coded included articles for risk of bias and extracted data using a prepiloted extraction sheet.

RESULTS

We identified 29 eligible articles: 14 qualitative, 11 quantitative, and 4 mixed methods. We identified the following themes: patient factors, health professional factors, the therapeutic relationship, therapy factors, organizational and system factors, and models of care. Health professionals supported web-based therapies only for patients with relatively straightforward, low-risk diagnoses, strong motivation and engagement, high computer literacy and access, and low need for tailored content. They perceived flexibility with timing and location as advantages of web-based therapy, but preferred blended therapy to facilitate rapport and allow active monitoring and follow-up of patients. They emphasized the need for targeted training and organizational support to manage changed workflows. Health professionals were concerned about the confidentiality and security of client data for web-based programs, suggesting that clear and transparent protocols need to be in place to reassure health professionals before they will be willing to refer.

CONCLUSIONS

Without health professionals' support, many people will not access web-based therapies. To increase uptake, it is important to ensure that health professionals receive education, familiarization, and training to support them in incorporating web-based therapies into their practice, and to design systems that support health professionals in this new way of working with patients and addressing their concerns.

TRIAL REGISTRATION

PROSPERO CRD42018100869; https://tinyurl.com/y5vaoqsk.

Efficacy of a Guided Web-Based Self-Management Intervention for Depression or Dysthymia: Randomized Controlled Trial With a 12-Month Follow-Up Using an Active Control Condition

BACKGROUND

An increasing number of studies suggest that web-based interventions for patients with depression can reduce their symptoms and are expected to fill currently existing treatment gaps. However, evidence for their efficacy has mainly been derived from comparisons with wait-list or treatment as usual controls. In particular, designs using wait-list controls are unlikely to induce hope and may even have nocebo effects, making it difficult to draw conclusions about the intervention's efficacy. Studies using active controls are rare and have not yielded conclusive results.

OBJECTIVE

The main objective of this study is to assess the acute and long-term antidepressant efficacy of a 6-week, guided, web-based self-management intervention building on the principles of cognitive behavioral therapy (iFightDepression tool) for patients with depression compared with web-based progressive muscle relaxation as an active control condition.

METHODS

A total of 348 patients with mild-to-moderate depressive symptoms or dysthymia (according to the Mini International Neuropsychiatric Interview) were recruited online and randomly assigned to 1 of the 2 intervention arms. Acute antidepressant effects after 6 weeks and long-term effects at 3-, 6-, and 12-month follow-up were studied using the Inventory of Depressive Symptomatology-self-rating as a primary outcome parameter and change in quality of life (Short Form 12) and user satisfaction (client satisfaction questionnaire) as secondary outcome parameters. Treatment effects were assessed using mixed model analyses.

RESULTS

Over the entire observation period, a greater reduction in symptoms of depression (P=.01) and a greater improvement of life quality (P<.001) was found in the intervention group compared with the active control group. Separate tests for each time point revealed significant effects on depressive symptoms at the 3-month follow-up (d=0.281; 95% CI 0.069 to 0.493), but not after 6 weeks (main outcome:d=0.192; 95% CI -0.020 to 0.404) and 6 and 12 months. The intervention was significantly superior to the control condition with respect to user satisfaction (25.31 vs 21.97; t₂₅₉=5.804; P<.01).

CONCLUSIONS

The fact that antidepressant effects have been found for a guided self-management tool in comparison with an active control strengthens the evidence base for the efficacy of web-based interventions. The antidepressant effect became most prominent at the 3-month follow-up. After 6 weeks of intervention, significant positive effects were observed on life quality but not on depressive symptoms. Although the effect size of such web-based interventions on symptoms of depression might be smaller than that suggested by earlier studies using wait-list control conditions, they can be a cost-effective addition to antidepressants and face-to-face psychotherapy.

TRIAL REGISTRATION

International Clinical Trials Registry Platform ICTRP080-15-09032015; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00009323.

Development and testing of iAware model for ubiquitous care of patients with symptoms of stress, anxiety and depression

BACKGROUND AND OBJECTIVE

This work proposes a model for ubiquitous care of patients with anxiety, depression and stress disorders using gamification and biodata, called iAware. Depression and anxiety are the most prevalent mental disorders, reaching million people worldwide. As they share many characteristics these two disorders can manifest themselves together. In addition, stress is one of the related factors with both depression and anxiety, being relevant in the analysis of these disorders. This work was carried out through a study on depression, anxiety and stress disorders (DASD), their treatments and the use of gamification as a means of engagement.

METHODS

A/B tests evaluated with a clinical population the interaction engagement of the patient to the treatment provided by gamification. The iAware monitors and applies interventions for the patient at the most appropriate time, based on the patient's history. In order to evaluate iAware, six patients used a prototype with a smartband for two weeks. The patients also filled out a survey based on the Technology Acceptance Model (TAM). The survey was composed of 10 sentences and the results of each one are discussed.

RESULTS

Interactions with intervention stages were greater in patients who used iAware gamified. The patients who used iAware got more occurrences of anxiety at home and in the afternoon and night. TAM evaluation showed that patients considered the use of iAware useful in their anxiety treatment routine.

CONCLUSIONS

The results pointed out that biodata is a supplementary alternative for DASD monitoring. In addition, the research work showed that the use of iAware for the support of anxiety treatment is useful for patients. Patients who used iAware without gamification did not perform or score the treatment activities. The evaluation showed evidence that the game improved the engagement of patients in the iAware use.

ACTsmart - development and feasibility of digital Acceptance and Commitment Therapy for adults with chronic pain

Accessibility of evidence-based behavioral health interventions is one of the main challenges in health care and effective treatment approaches are not always available for patients that would benefit from them. Digitization has dramatically changed the health care landscape. Although mHealth has shown promise in addressing issues of accessibility and reach, there is vast room for improvements. The integration of technical innovations and theory driven development is a key concern. Digital solutions developed by industry alone often lack a clear theoretical framework and the solutions are not properly evaluated to meet the standards of scientifically proven efficacy. On the other hand, mHealth interventions developed in academia may be theory driven but lack user friendliness and are commonly technically outdated by the time they are implemented in regular care, if they ever are. In an ongoing project aimed at scientific innovation, the mHealth Agile Development and Evaluation Lifecycle was used to combine strengths from both industry and academia in the development of ACTsmart - a smartphone-based Acceptance and Commitment Therapy treatment for adult chronic pain patients. The present study describes the early development of ACTsmart, in the process of moving the product from alpha testing to a clinical trial ready solution.

Internet-Delivered Cognitive Behavior Therapy as a Prequel to Face-To-Face Therapy for Depression and Anxiety: A Naturalistic Observation

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.

The Role of the Patient-Centered Medical Home in Treating Depression

PURPOSE OF REVIEW

This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH.

RECENT FINDINGS

Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.

Stakeholder perspectives on evidence for digital mental health interventions: Implications for accreditation systems

Background

Digital mental health interventions can be effective for treating mental health problems, but uptake by consumers and clinicians is not optimal. The lack of an accreditation pathway for digital mental health interventions is a barrier to their uptake among clinicians and consumers. However, there are a number of factors that may contribute to whether a digital intervention is suitable for recommendation to the public. The aim of this study was to identify the types of evidence that would support the accreditation of digital interventions.

Method

An expert workshop was convened, including researcher, clinician, consumer (people with lived experience of a mental health condition) and policymaker representatives.

Results

Existing methods for assessing the evidence for digital mental health interventions were discussed by the stakeholders present at the workshop. Empirical evidence from randomised controlled trials was identified as a key component for evaluating digital interventions. However, information on the safety of users, data security, user ratings, and fidelity to clinical guidelines, along with data from routine care including adherence, engagement and clinical outcomes, were also identified as important considerations when evaluating an intervention. There are considerable challenges in weighing the evidence for a digital mental health intervention.

Conclusions

Empirical evidence should be the cornerstone of any accreditation system to identify appropriate digital mental health interventions. However, robust accreditation systems should also account for program and user safety, user engagement and experience, and fidelity to clinical treatment guidelines.

Reboot Online: A Randomized Controlled Trial Comparing an Online Multidisciplinary Pain Management Program with Usual Care for Chronic Pain

Objective

Chronic pain is a prevalent and burdensome condition. Reboot Online was developed to address treatment barriers traditionally associated with accessing face-to-face chronic pain management programs. It is a comprehensive multidisciplinary online treatment program, based on an existing and effective face-to-face multidisciplinary pain program (the Reboot program).

Design & Participants

A CONSORT-compliant randomized controlled trial was conducted, enrolling adults who had experienced pain for three months or longer.

Methods

Participants were randomly allocated to either an eight-lesson multidisciplinary pain management program, Reboot Online (N = 41), or to a usual care (UC) control group (N = 39). Clinical oversight was provided by a multidisciplinary team remotely, including physiotherapists and clinical psychologists. Participants were measured at baseline, post-treatment (week 16), and three-month follow-up (week 28).

Results

Intention-to-treat analyses revealed that Reboot Online was significantly more effective than UC at increasing pain self-efficacy (g = 0.69) at post-treatment, and these gains were maintained at follow-up. Similarly, Reboot Online was significantly more effective than UC on several secondary measures at post-treatment and follow-up, including movement-based fear avoidance and pain-related disability, but it did not significantly reduce pain interference or depression compared with UC. Clinician input was minimal, and adherence to Reboot Online was moderate, with 61% of participants (N = 25) completing all eight lessons.

Conclusions

Reboot Online presents a novel approach to multidisciplinary pain management and offers an accessible, efficacious alternative and viable treatment option for chronic pain management.

Mental health and HIV/AIDS: the need for an integrated response

Tremendous biomedical advancements in HIV prevention and treatment have led to aspirational efforts to end the HIV epidemic. However, this goal will not be achieved without addressing the significant mental health and substance use problems among people living with HIV (PLWH) and people vulnerable to acquiring HIV. These problems exacerbate the many social and economic barriers to accessing adequate and sustained healthcare, and are among the most challenging barriers to achieving the end of the HIV epidemic. Rates of mental health problems are higher among both people vulnerable to acquiring HIV and PLWH, compared with the general population. Mental health impairments increase risk for HIV acquisition and for negative health outcomes among PLWH at each step in the HIV care continuum. We have the necessary screening tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment with appropriate resources to address the current mental health screening and treatment gaps. Integration of mental health screening and care into all HIV testing and treatment settings would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare.

Health Care Providers' Profiles and Evaluations of a Statewide Online Education Program for Dissemination of Clinical Evidence on HIV, Hepatitis C Virus, and Sexually Transmitted Disease: Cross-Sectional Study

BACKGROUND

Timely and effective dissemination of the latest clinical evidence to health care providers is essential for translating biomedical research into routine patient care. Online platforms offer unique opportunities for dissemination of medical knowledge.

OBJECTIVE

In this study, we report the profiles of health care providers participating in the New York State HIV-HCV-STD Clinical Education Initiative online program and their evaluations of the online continuing professional development courses.

METHODS

We compiled professional and personal background information of the clinicians who completed at least one online course. We collected their self-reported program evaluation data with regard to the course content, format, knowledge increase, and impact on clinical practice.

RESULTS

We recorded a total of 4363 completions of 88 online courses by 1976 unique clinicians during a 12-month study period. The clinicians' background was diverse in terms of demographics, education levels, professional disciplines, practice years, employment settings, caseloads, and clinical services. The evaluation of online courses was very positive (usefulness/relevance, 91.08%; easy comprehension, 89.09%; knowledgeable trainer, 92.00%; appropriate format, 84.35%; knowledge increase, 48.52%; intention to use knowledge, 85.26%; and plan to change practice, 21.98%). Comparison with the reference data indicated that the online program successfully reached out to the primary care communities. Both the younger generation and the senior health care providers were attracted to the online program. High-quality multimedia resources, flexibility of access, ease of use, and provision of continuing professional development credits contributed to the initial success of this online clinical education program.

CONCLUSIONS

We have successfully characterized a diverse group of clinicians participating in a statewide online continuing professional development program. The evaluation has shown effective use of online resources to disseminate clinical evidence on HIV, hepatitis C virus, and sexually transmitted disease to primary care clinicians.

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis

PURPOSE

Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care.

METHODS

We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool.

RESULTS

Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness.

LIMITATIONS

The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety.

CONCLUSIONS

E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.

Guided internet CBT versus "gold standard" depression treatments: An individual patient analysis

OBJECTIVE

Guided, computerized cognitive behavioral therapy delivered over the internet (iCBT) is a promising treatment for depression. However, comparisons to "gold standard" treatments and comparators, such as structured psychotherapy, medications, or pill placebo are rare. We compare the results of an 8-week trial of guided iCBT to outcomes from two trials of depression treatment, Penn-Vandy and U. Washington, using individual patient data.

METHOD

We adjusted for sample differences by restricting the iCBT sample to randomised controlled trial (RCT) inclusion criteria and using propensity scores. Three separate samples were included in analyses: iCBT trial (N = 89), Penn-Vandy (N = 240), and U. Washington (N = 241). Continuous outcomes were analyzed with linear-mixed models and noninferiority analyses were conducted for iCBT versus the psychotherapy conditions. The primary outcomes were attrition, remission, and the Hamilton Rating Scale for Depression.

RESULTS

Dropout was greater in iCBT than in CT, medications, placebo (Penn-Vandy), and CT and BA (U. Washington), but the rates of remission were similar. In continuous analyses, iCBT was superior to placebo in both RCTs and most analyses indicated no difference between iCBT and the active treatments.

CONCLUSIONS

Guided iCBT appears not inferior to "gold standard" treatments for depression and is superior to placebo. Weaknesses include a lack of randomization, unblinded assessments, and a shorter "frame of treatment" in the iCBT sample.

Therapist-Assisted Internet-Based Cognitive Behavioral Therapy Versus Progressive Relaxation in Obsessive-Compulsive Disorder: Randomized Controlled Trial

Background

Obsessive-compulsive disorder (OCD) is a highly disabling psychological disorder with a chronic course if left untreated. Cognitive behavioral therapy (CBT) has been shown to be an effective treatment, but access to face-to-face CBT is not always possible. Internet-based CBT (iCBT) has become an increasingly viable option. However, no study has compared iCBT to an analogous control condition using a randomized controlled trial (RCT).

Objective

A 2-armed RCT was used to compare a therapist-assisted 12-module iCBT to an analogous active attention control condition (therapist-assisted internet-based standard progressive relaxation training, iPRT) in adult OCD. This paper reports pre-post findings for OCD symptom severity.

Method

In total, 179 participants (117 females, 65.7%) were randomized (stratified by gender) into iCBT or iPRT. The iCBT intervention included psychoeducation, mood and behavioral management, exposure and response prevention (ERP), cognitive therapy, and relapse prevention; the iPRT intervention included psychoeducation and relaxation techniques as a way of managing OCD-related anxiety but did not incorporate ERP or other CBT elements. Both treatments included audiovisual content, case stories, demonstrations of techniques, downloadable audio content and worksheets, and expert commentary. All participants received 1 weekly email, with a maximum 15-minute preparation time per client from a remote therapist trained in e-therapy. Emails aimed to monitor progress, provide support and encouragement, and assist in individualizing the treatment. Participants were assessed for baseline and posttreatment OCD severity with the telephone-administered clinician-rated Yale-Brown Obsessive-Compulsive Scale and other measures by assessors who were blinded to treatment allocation.

Results

No pretreatment differences were found between the 2 conditions. Intention-to-treat analysis revealed significant pre-post improvements in OCD symptom severity for both conditions (P<.001). However, relative to iPRT, iCBT showed significantly greater symptom severity improvement (P=.001); Cohen d for iCBT was 1.05 (95% CI 0.72-1.37), whereas for iPRT it was 0.48 (95% CI 0.22-0.73). The iCBT condition was superior in regard to reliable improvement (25/51, 49% vs 16/55, 29%; P=.04) and clinically significant pre-post-treatment changes (17/51, 33% vs 6/55, 11%; P=.005). Those undertaking iCBT post completion of iPRT showed further significant symptom amelioration (P<.001), although the sequential treatment was no more efficacious than iCBT alone (P=.63).

Conclusion

This study is the first to compare a therapist-assisted iCBT program for OCD to an analogous active attention control condition using iPRT. Our findings demonstrate the large magnitude effect of iCBT for OCD; interestingly, iPRT was also moderately efficacious, albeit significantly less so than the iCBT intervention. The findings are compared to previous internet-based and face-to-face CBT treatment programs for OCD. Future directions for technology-enhanced programs for the treatment of OCD are outlined.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12611000321943; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336704 (Archived by WebCite at http://www.webcitation.org/70ovUiOmd)

Priming attachment security improves attitudes towards a range of therapies

We sought to understand how attachment orientation influenced attitudes towards different types of psychological therapies. In two studies, we (1) examined attachment orientation as a predictor of attitudes towards different therapies and (2) tested whether attachment security priming could improve attitudes. Study 1 (n = 339) found associations between attachment orientation and attitudes towards, and likelihood of using different therapies. Positive and negative attitudes about different therapies mediated the relationship between attachment avoidance and likelihood of use. Study 2 (n = 412) showed that primed security (vs. neutral prime) improved attitudes towards relational, non-relational and distanced-relational therapies for those with a fearful-avoidant attachment orientation. For relational and distanced-relational therapies, the mechanism of this effect was increased cognitive openness. Attachment orientation is a determinant of therapy attitudes and anticipated help-seeking behaviour. Priming security may promote open-minded decision-making about some therapies. Findings are discussed with relevance to attachment theory, research and clinical practice.

The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: A systematic review and meta-analysis

Computer-based interventions target improvement of physical and emotional functioning in patients with chronic pain and functional somatic syndromes. However, it is unclear to what extent which interventions work and for whom. This systematic review and meta-analysis (registered at PROSPERO, 2016: CRD42016050839) assesses efficacy relative to passive and active control conditions, and explores patient and intervention factors. Controlled studies were identified from MEDLINE, EMBASE, PsychInfo, Web of Science, and Cochrane Library. Pooled standardized mean differences by comparison type, and somatic symptom, health-related quality of life, functional interference, catastrophizing, and depression outcomes were calculated at post-treatment and at 6 or more months follow-up. Risk of bias was assessed. Sub-group analyses were performed by patient and intervention characteristics when heterogeneous outcomes were observed. Maximally, 30 out of 46 eligible studies and 3,387 participants were included per meta-analysis. Mostly, internet-based cognitive behavioral therapies were identified. Significantly higher patient reported outcomes were found in comparisons with passive control groups (standardized mean differences ranged between -.41 and -.18), but not in comparisons with active control groups (SMD = -.26 - -.14). For some outcomes, significant heterogeneity related to patient and intervention characteristics. To conclude, there is a minority of good quality evidence for small positive average effects of computer-based (cognitive) behavior change interventions, similar to traditional modes. These effects may be sustainable. Indications were found as of which interventions work better or more consistently across outcomes for which patients. Future process analyses are recommended in the aim of better understanding individual chances of clinically relevant outcomes.

Evaluation of the implementation of an internet intervention in well-baby clinics: A pilot study

PURPOSE

Despite promising results, internet interventions are not widely accessible or well-integrated in health services. The objective of this study was, therefore, to examine the implementation of an internet intervention ('Mamma Mia') for the prevention of perinatal depression in Norwegian well-baby clinics (i.e., primary care).

METHODS

Mamma Mia begins in mid-pregnancy and lasts up to 6 months after childbirth. It consists of 44 online sessions, supported by midwives and public health nurses at up to 5 contact points during this period, following principles of empathic communication. Well-baby clinics offer free, universal services to all pregnant women and children aged 0 to 5 years in Norway and were recruited via an intermediary organization for this study. Data were collected at pre- and post-training, but before the delivery of Mamma Mia in clinics, and at 3 and 6 months follow-up. Quantitative and qualitative data were used to evaluate the training in Mamma Mia, examine program implementation (i.e., number of pregnant women registered for the program), and identify barriers and enablers of implementation.

RESULTS

Twenty-four self-selected healthcare professionals from 14 well-baby clinics were recruited, for this study. Training increased participants' knowledge about Mamma Mia and exceeded their expectations. The program review and implementation plan were necessary training components. Implementation climate was related to the number of colleagues working with Mamma Mia and overall satisfaction with implementation, while characteristics of the intervention predicted the number of registered women at 6 months. Organizational re-structuring, leadership, and competing activities were identified as barriers to implementation that need to be considered further.

CONCLUSIONS

The dissemination and implementation of a health-service supported internet intervention appears to be promising but requires further research.

Impact and change of attitudes toward Internet interventions within a randomized controlled trial on individuals with depression symptoms

BACKGROUND

Most individuals with depression do not receive adequate treatment. Internet interventions may help to bridge this gap. Research on attitudes toward Internet interventions might facilitate the dissemination of such interventions by identifying factors that help or hinder uptake and implementation, and by clarifying who is likely to benefit. This study examined whether attitudes toward Internet interventions moderate the effects of a depression-focused Internet intervention, and how attitudes change over the course of treatment among those who do or do not benefit.

METHODS

We recruited 1,004 adults with mild-to-moderate depression symptoms and investigated how attitudes toward Internet interventions are associated with the efficacy of the program deprexis, and how attitudes in the intervention group change from pre to post over a 3 months intervention period, compared to a control group (care as usual). This study consists of a subgroup analysis of the randomized controlled EVIDENT trial.

RESULTS

Positive initial attitudes toward Internet interventions were associated with greater efficacy (η²_p  = .014) independent of usage time, whereas a negative attitude (perceived lack of personal contact) was associated with reduced efficacy (η²_p  = .012). Users' attitudes changed during the trial, and both the magnitude and direction of attitude change were associated with the efficacy of the program over time (η²_p  = .030).

CONCLUSIONS

Internet interventions may be the most beneficial for individuals with positive attitudes toward them. Informing potential users about evidence-based Internet interventions might instill positive attitudes and thereby optimize the benefits such interventions can provide. Assessing attitudes prior to treatment might help identify suitable users.

Maladaptive Behaviours Associated with Generalized Anxiety Disorder: An Item Response Theory Analysis

Background: Cognitive models of generalized anxiety disorder (GAD) suggest that maladaptive behaviours may contribute to the maintenance of the disorder; however, little research has concentrated on identifying and measuring these behaviours. To address this gap, the Worry Behaviors Inventory (WBI) was developed and has been evaluated within a classical test theory (CTT) approach. Aims: As CTT is limited in several important respects, this study examined the psychometric properties of the WBI using an Item Response Theory approach. Method: A large sample of adults commencing treatment for their symptoms of GAD (n = 537) completed the WBI in addition to measures of GAD and depression symptom severity. Results: Patients with a probable diagnosis of GAD typically engaged in four or five maladaptive behaviours most or all of the time in an attempt to prevent, control or avoid worrying about everyday concerns. The two-factor structure of the WBI was confirmed, and the WBI scales demonstrated good reliability across a broad range of the respective scales. Together with previous findings, our results suggested that hypervigilance and checking behaviours, as well as avoidance of saying or doing things that are worrisome, were the most relevant maladaptive behaviours associated with GAD, and discriminated well between adults with low, moderate and high degrees of the respective WBI scales. Conclusions: Our results support the importance of maladaptive behaviours to GAD and the utility of the WBI to index these behaviours. Ramifications for the classification, theoretical conceptualization and treatment of GAD are discussed.

Implementation of a Guided, Digital Cognitive Behavioral Program for Anxiety in Primary Care: Preliminary Findings of Engagement and Effectiveness

BACKGROUND

Implementation of digital behavioral health programs in primary care (PC) can improve access to care for patients in need.

INTRODUCTION

This study provides preliminary data on user engagement and anxiety symptom change among patients referred by their PC provider to a guided, mobile cognitive behavioral program, Lantern.

MATERIALS AND METHODS

Adults aged 20-65 years with at least mild anxiety (GAD-7 ≥ 5) during routine clinical screening in two PC practices were offered Lantern. The primary outcome was self-reported anxiety collected at baseline and 2 months. Linear mixed effects modeling was used to examine anxiety symptom reduction from baseline to 2 months. Post hoc analyses evaluated how number of units completed, number of techniques practiced, and days of usage impacted symptom change.

RESULTS

Sixty-three participants signed up for Lantern and had both baseline and 2- month GAD-7. A mixed effects model adjusted for age, gender, medical complexity score, and physical health found a significant effect of time on GAD-7 (β = -2.08, standard error = 0.77, t(62) = -2.71, p = 0.009). Post hoc analyses indicated that mean number of units, techniques, and usage days did not significantly impact GAD-7 change over 2 months. However, there was significantly greater improvement in anxiety in participants who completed at least three techniques.

DISCUSSION

Results benchmark to previous studies that have found statistically significant symptom change among participants after 4-9 weeks of face-to-face or Internet-based cognitive behavioral therapy (CBT).

CONCLUSIONS

This study suggests that use of Lantern is associated with anxiety reduction and provides proof-of-concept for the dissemination and implementation of guided, CBT-based mobile behavioral health interventions in PC settings.

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

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

Effective strategies for scaling up evidence-based practices in primary care: a systematic review

Background

While an extensive array of existing evidence-based practices (EBPs) have the potential to improve patient outcomes, little is known about how to implement EBPs on a larger scale. Therefore, we sought to identify effective strategies for scaling up EBPs in primary care.

Methods

We conducted a systematic review with the following inclusion criteria: (i) study design: randomized and non-randomized controlled trials, before-and-after (with/without control), and interrupted time series; (ii) participants: primary care-related units (e.g., clinical sites, patients); (iii) intervention: any strategy used to scale up an EBP; (iv) comparator: no restrictions; and (v) outcomes: no restrictions. We searched MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and the Cochrane Library from database inception to August 2016 and consulted clinical trial registries and gray literature. Two reviewers independently selected eligible studies, then extracted and analyzed data following the Cochrane methodology. We extracted components of scaling-up strategies and classified them into five categories: infrastructure, policy/regulation, financial, human resources-related, and patient involvement. We extracted scaling-up process outcomes, such as coverage, and provider/patient outcomes. We validated data extraction with study authors.

Results

We included 14 studies. They were published since 2003 and primarily conducted in low-/middle-income countries (n = 11). Most were funded by governmental organizations (n = 8). The clinical area most represented was infectious diseases (HIV, tuberculosis, and malaria, n = 8), followed by newborn/child care (n = 4), depression (n = 1), and preventing seniors’ falls (n = 1). Study designs were mostly before-and-after (without control, n = 8). The most frequently targeted unit of scaling up was the clinical site (n = 11). The component of a scaling-up strategy most frequently mentioned was human resource-related (n = 12). All studies reported patient/provider outcomes. Three studies reported scaling-up coverage, but no study quantitatively reported achieving a coverage of 80% in combination with a favorable impact.

Conclusions

We found few studies assessing strategies for scaling up EBPs in primary care settings. It is uncertain whether any strategies were effective as most studies focused more on patient/provider outcomes and less on scaling-up process outcomes. Minimal consensus on the metrics of scaling up are needed for assessing the scaling up of EBPs in primary care.

Trial registration

This review is registered as PROSPERO CRD42016041461.

Electronic supplementary material

The online version of this article (10.1186/s13012-017-0672-y) contains supplementary material, which is available to authorized users.

Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods

Background

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise.

Objective

The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects.

Methods

Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training.

Results

A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92).

Conclusions

Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

Internet interventions for depression: new developments

A wide range of Internet interventions, mostly grounded in methods of cognitive behavioral therapy, have been developed and tested for several mental disorders. The evidence to date shows that these interventions are effective in reducing symptoms of depression. Metaanalyses report small-to-medium effect sizes when Internet interventions are delivered as stand-alone self-help interventions (d=0.25-0.36), and medium-to-large effect sizes when delivered as therapist-guided interventions (d=0.58-0.78), both compared with usual care. Only a minority of people suffering from depression receive adequate treatment, and Internet interventions might help bridge the large treatment gap. This review summarizes the current body of evidence and highlights pros and cons of Internet interventions. It also outlines how they could be implemented in mental health care systems and points out unresolved questions, as well as future directions, in this research field.

Help from home for depression: A randomised controlled trial comparing internet-delivered cognitive behaviour therapy with bibliotherapy for depression

Major Depressive Disorder (MDD) is a leading cause of the Global Burden of Disease. Cognitive Behavioural Therapy (CBT) is an effective treatment for MDD, but access can be impaired due to numerous barriers. Internet-delivered CBT (iCBT) can be utilised to overcome treatment barriers and is an effective treatment for depression, but has never been compared to bibliotherapy. This Randomised Controlled Trial (RCT) included participants meeting diagnostic criteria for MDD (n = 270) being randomised to either: iCBT (n = 61), a CBT self-help book (bCBT) (n = 77), a meditation self-help book (bMED) (n = 64) or wait-list control (WLC) (n = 68). The primary outcome was the Patient Health Questionnaire 9-item scale (PHQ-9) at 12-weeks (post-treatment). All three active interventions were significantly more effective than WLC in reducing depression at post-treatment, but there were no significant differences between the groups. All three interventions led to large within-group reductions in PHQ-9 scores at post-treatment (g = 0.88-1.69), which were maintained at 3-month follow-up, although there was some evidence of relapse in the bMED group (within-group g [post to follow-up] = 0.09-1.04). Self-help based interventions could be beneficial in treating depression, however vigilance needs to be applied when selecting from the range of materials available. Replication of this study with a larger sample is required.

A Web-Based Public Health Intervention to Reduce Functional Impairment and Depressive Symptoms in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial Protocol

Background

Depressive symptoms are common in people with type 2 diabetes and contribute to adverse health consequences that substantially impact social and vocational function. Despite the existence of effective depression treatments, the majority of people with type 2 diabetes do not access these when needed. Web-based alternatives to more traditional psychotherapies offer a potential solution to reducing the personal and economic burdens of type 2 diabetes.

Objective

This paper outlines the protocol for a randomized controlled trial (RCT) of myCompass, a Web-based public health psychotherapy intervention, in people with type 2 diabetes. Fully automated, interactive, and delivered via the Internet without clinician support, myCompass teaches cognitive behavioral therapy-based skills and supports symptom monitoring to improve daily functioning and reduce mild-to-moderate mental health symptoms.

Methods

A two-arm RCT will be conducted. People with type 2 diabetes and mild-to-moderately severe depressive symptoms will be recruited from the community and general practice settings. Screening and enrollment is via an open-access website. Participants will be randomized to use either myCompass or an active placebo program for 8 weeks, followed by a 4-week tailing-off period. The placebo program is matched to myCompass on mode of delivery, interactivity, and duration. Outcomes will be assessed at baseline and at 3-month, 6-month, and 12-month follow-up. The primary study outcome is work and social functioning. Secondary study outcomes include depressive and anxious symptoms, diabetes-related distress, self-care behaviors, and glycemic control.

Results

Nationwide recruitment is currently underway with the aim of recruiting 600 people with type 2 diabetes. Recruitment will continue until October 2017.

Conclusions

This is the first known trial of a Web-based psychotherapy program that is not diabetes specific for improving social and vocational function in people with type 2 diabetes and mild-to-moderately severe depressive symptoms. With the increasing prevalence of type 2 diabetes and depression, a potentially scalable public health intervention could play a very large role in reducing unmet mental health need and ameliorating the personal and societal impact of illness comorbidity.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109 (Archived by WebCite at http://www.webcitation.org/ 6rh3imVMh)

Protocol for the ENCODE trial: evaluating a novel online depression intervention for persons with epilepsy

BACKGROUND

Depression is common among persons with epilepsy (PwE), affecting roughly one in three individuals, and its presence is associated with personal suffering, impaired quality of life, and worse prognosis. Despite the availability of effective treatments, depression is often overlooked and treated inadequately in PwE, in part because of assumed concerns over drug interactions or proconvulsant effects of antidepressants. Internet-administered psychological interventions might complement antidepressant medication or psychotherapy, and preliminary evidence suggests that they can be effective. However, no trial has yet examined whether an Internet intervention designed to meet the needs of PwE can achieve sustained reductions in depression and related symptoms, such as anxiety, when offered as adjunct to treatment as usual.

METHODS/DESIGN

This randomized controlled trial will include 200 participants with epilepsy and a current depressive disorder, along with currently at least moderately elevated depression (Patient Health Questionnaire (PHQ-9) sum score of at least 10). Patients will be recruited via epilepsy treatment centers and other sources, including Internet forums, newspaper articles, flyers, posters, and media articles or advertisements, in German-speaking countries. Main inclusion criteria are: self-reported diagnosis of epilepsy and a depressive disorder, as assessed with a phone-administered structured diagnostic interview, none or stable antidepressant medication, no current psychotherapy, no other major psychiatric disorder, no acute suicidality. Participants will be randomly assigned to either (1) a care-as-usual/waitlist (CAU/WL) control group, in which they receive CAU and are given access to the Internet intervention after 3 months (that is, a CAU/WL control group), or (2) a treatment group that may also use CAU and in addition immediately receives six-month access to the novel, Internet-administered intervention. The primary outcome measure is the PHQ-9, collected at three months post-baseline; secondary measures include self-reported anxiety, work and social adjustment, epilepsy symptoms (including seizure frequency and severity), medication adherence, potential negative treatment effects and health-related quality of life. Measurements are collected online at pre-treatment (T0), three months (T1), six months (T2), and nine months (T3).

DISCUSSION

Results of this trial are expected to extend the body of knowledge with regard to effective and efficient treatment options for PwE who experience elevated depression and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02791724 . Registered 01 June 2016.

Guided Internet-based cognitive behavioral therapy for mild and moderate depression: A benchmarking study

Major depression is among the most common and debilitating disorders worldwide, associated with large societal and individual costs. Effective treatments exist, but accessibility is scarce. Guided Internet-Based Cognitive Behavioral Therapy (guided iCBT) is a promising approach to reach more people in need of help. In the present pilot study, we investigated the outcome of a guided iCBT program for mild and moderate depression when disseminated from Sweden to Norway. The guided iCBT intervention was implemented within a university-based outpatient clinic by six student therapists under supervision. Twenty-two participants with mild and moderate depression were included in the study. Large treatment effects were found for depressive symptoms, whereas small to medium effects were observed for anxiety symptoms. More than half (55%) of the participants were classified as recovered at post-treatment and more than a third (41%) at follow-up. No participants had a significant deterioration from pre- to post-treatment, but two reported a significant deterioration from post-treatment to 6-month follow-up. Benchmarking the present results against those reported in the four original Swedish studies, we found that the treatment effect in the Norwegian study was slightly higher at post-treatment and slightly lower at 6-month follow-up compared to the outcome in the Swedish studies. The results should be interpreted with caution, as our sample was small and had no control group.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

The Worry Behaviors Inventory: Assessing the behavioral avoidance associated with generalized anxiety disorder

BACKGROUND

Understanding behavioral avoidance associated with generalized anxiety disorder (GAD) has implications for the classification, theoretical conceptualization, and clinical management of the disorder. This study describes the development and preliminary psychometric evaluation of a self-report measure of avoidant behaviors associated with GAD: the Worry Behaviors Inventory (WBI).

METHODS

The WBI was administered to treatment-seeking patients (N=1201). Convergent validity was assessed by correlating the WBI with measures of GAD symptom severity. Divergent validity was assessed by correlating the WBI with measures of general disability and measures of depression, social anxiety and panic disorder symptom severity.

RESULTS

Exploratory and confirmatory factor analyses supported a two-factor structure (Safety Behaviors and Avoidance). Internal reliability was acceptable for the 10-item WBI scale (α=.86), Safety Behaviors (α=.85) and Avoidance subscales (α=.75). Evidence of convergent, divergent, and discriminant validity is reported. WBI subscales demonstrated differential associations with measures of symptom severity. The Safety Behaviors subscale was more strongly associated with GAD symptoms than symptoms of other disorders, whereas the Avoidance subscale was as strongly correlated with GAD severity as it was with depression, social anxiety and panic disorder severity.

LIMITATIONS

Structured diagnostic interviews were not conducted therefor validity analyses are limited to probable diagnoses based on self-report. The cross-sectional design precluded examination of the WBI's temporal stability and treatment sensitivity.

CONCLUSIONS

Preliminary evidence supports the use of the WBI in research and clinical settings and may assist clinicians to identify behaviors that are theorized to maintain GAD and that can be targeted during psychological treatment.

The Implementation of Internet Interventions for Depression: A Scoping Review

BACKGROUND

Depression is one of the most common mental health problems among adults, but effective treatments are not widely accessible. The Internet holds promise as a cost-effective and convenient delivery platform of interventions for depression. However, studies suggest that Internet interventions are not widely available in routine settings.

OBJECTIVE

The aim of this study was to review the literature and examine whether there are systematic differences in reporting of the various implementation components on Internet interventions for depression, and then to examine what is known about and is characteristic of the implementation of these Internet interventions in regular care settings.

METHODS

We performed a scoping review, drawing upon a broad range of the literature on Internet interventions for depression in regular care, and used the active implementation framework to extract data.

RESULTS

Overall, the results suggested that knowledge about the implementation of Internet interventions for depression in regular care is limited. However, guided support from health professionals emphasizing program adherence and recruitment of end users to the interventions emerged as 2 main themes. We identified 3 additional themes among practitioners, including their qualifications, training, and supervision, but these were scarcely described in the literature. The competency drivers (ie, staff and user selection, training, and supervision) have received the most attention, while little attention has been given to organizational (ie, decision support, administration, and system intervention) and leadership drivers.

CONCLUSIONS

Research has placed little emphasis on reporting on the implementation of interventions in practice. Leadership and organizational drivers, in particular, have been largely neglected. The results of this scoping review have implications for future research and efforts to successfully implement Internet interventions for depression in regular care.

The potential of low-intensity and online interventions for depression in low- and middle-income countries

The World Health Organization (WHO) reports that low- and middle-income countries (LMICs) are confronted with a serious 'mental health gap', indicating an enormous disparity between the number of individuals in need of mental health care and the availability of professionals to provide such care (WHO in 2010). Traditional forms of mental health services (i.e. face-to-face, individualised assessments and interventions) are therefore not feasible. We propose three strategies for addressing this mental health gap: delivery of evidence-based, low-intensity interventions by non-specialists, the use of transdiagnostic treatment protocols, and strategic deployment of technology to facilitate access and uptake. We urge researchers from all over the world to conduct feasibility studies and randomised controlled studies on the effect of low-intensity interventions and technology supported (e.g. online) interventions in LMICs, preferably using an active control condition as comparison, to ensure we disseminate effective treatments in LMICs.

Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care

BACKGROUND

Blended care combines face-to-face treatment with web-based components in mental health care settings. Blended treatment could potentially improve active patient participation, by letting patients work though part of the protocol autonomously. Further, blended treatment might lower the costs of mental health care, by reducing treatment duration and/or therapist contact. However, knowledge on blended care for depression is still limited.

OBJECTIVES

To develop a blended cognitive behavioural treatment (bCBT) for depressed patients in an outpatient specialized mental health care centre and to conduct a preliminary evaluation of this bCBT protocol.

METHOD

A bCBT protocol was developed, taking recommendations into account from depressed patients (n = 3) and therapists and experts in the field of e-health (n = 18). Next, an initial evaluation of integrated high-intensive bCBT was conducted with depressed patients (n = 9) in specialized mental health care. Patients' clinical profiles were established based on pre-treatment diagnostic information and patient self-reports on clinical measures. Patient treatment adherence rates were explored, together with patient ratings of credibility and expectancy (CEQ) before treatment, and system usability (SUS) and treatment satisfaction after treatment (CSQ-8). During and after treatment, the blended treatment protocol was evaluated in supervision sessions with the participating therapists (n = 7).

RESULTS

Seven out of nine patients started bCBT, of whom five completed ≥ 90% of treatment. System usability was evaluated as being above average (range 63 to 85), and patients were mostly to very satisfied with bCBT (range 16 to 32). Patients reported improvements in depression, health-related quality of life and anxiety. We observed that therapists evaluated the highly structured blended treatment as a helpful tool in providing evidence-based treatment to this complex patient group.

DISCUSSION

Although no conclusions can be drawn based on the current study, our observations suggest that a blended CBT approach might shorten treatment duration and has the potential to be a valuable treatment option for patients with severe depression in specialized mental health care settings. Further exploration of the effectiveness of our bCBT protocol by means of a randomized controlled trial is warranted.

Positive imagery cognitive bias modification (CBM) and internet-based cognitive behavioral therapy (iCBT): a randomized controlled trial

BACKGROUND

Accruing evidence suggests that positive imagery-based cognitive bias modification (CBM) could have potential as a standalone targeted intervention for depressive symptoms or as an adjunct to existing treatments. We sought to establish the benefit of this form of CBM when delivered prior to Internet cognitive behavioral therapy (iCBT) for depression

METHODS

A randomized controlled trial (RCT) of a 1-week Internet-delivered positive CBM vs. an active control condition for participants (N=75, 69% female, mean age=42) meeting diagnostic criteria for major depression; followed by a 10-week iCBT program for both groups.

RESULTS

Modified intent-to-treat marginal and mixed effect models demonstrated no significant difference between conditions following the CBM intervention or the iCBT program. In both conditions there were significant reductions (Cohen׳s d .57-1.58, 95% CI=.12-2.07) in primary measures of depression and interpretation bias (PHQ9, BDI-II, AST-D). Large effect size reductions (Cohen׳s d .81-1.32, 95% CI=.31-1.79) were observed for secondary measures of distress, disability, anxiety and repetitive negative thinking (K10, WHODAS, STAI, RTQ). Per protocol analyses conducted in the sample of participants who completed all seven sessions of CBM indicated between-group superiority of the positive over control group on depression symptoms (PHQ9, BDI-II) and psychological distress (K10) following CBM (Hedges g .55-.88, 95% CI=-.03-1.46) and following iCBT (PHQ9, K10). The majority (>70%) no longer met diagnostic criteria for depression at 3-month follow-up.

LIMITATIONS

The control condition contained many active components and therefore may have represented a smaller 'dose' of the positive condition.

CONCLUSIONS

Results provide preliminary support for the successful integration of imagery-based CBM into an existing Internet-based treatment for depression.