"Take Care of You" - Efficacy of integrated, minimal-guidance, internet-based self-help for reducing co-occurring alcohol misuse and depression symptoms in adults: Results of a three-arm randomized controlled trial

Internet-delivered therapy for alcohol misuse: engagement, satisfaction, and outcomes when patients select their preference for therapist- or self-guided treatment

BACKGROUND

Alcohol misuse is common and causes substantial harm. Internet-delivered cognitive behaviour therapy (ICBT) is effective in reducing alcohol misuse; however, the literature investigating how treatment outcomes are impacted by patients' preferences for therapist- versus self-guided ICBT for alcohol misuse is sparse.

METHODS

In this preference trial, 74 eligible patients (who reported ≥ 14 drinks in the previous week and obtained scores suggesting hazardous or harmful drinking) chose between enrolling in either therapist- or self-guided ICBT for alcohol misuse. We investigated whether those who chose therapist- versus self-guided ICBT differed in their (a) drinking outcomes-as measured by Timeline Follow-Back (TLFB) and heavy drinking days (HDD) at post-treatment and 3-month follow-up-and (b) post-treatment ICBT engagement and satisfaction.

RESULTS

The majority (81.1%) of eligible patients chose therapist-guided ICBT. These patients reported higher psychotropic medication use, drinking difficulties, and anxiety symptoms. For both the therapist- and self-guided patients, a modified intention-to-treat analysis revealed large within-group treatment effects for TLFB (β =  - 2.64, SE 0.66; p < 0.001) and HDD (β =  - 0.34, SE 0.07; p < 0.001), with large pre-to-post-treatment Cohen's effect sizes of d = 0.97 (95% CI [0.49, 1.45]) for TLFB and d = 1.19 (95% CI [0.69, 1.68]) for HDD. The interaction comparing the effects of therapist- to self-guided ICBT over time was not significant for TLFB (p = 0.34) or HDD (p = 0.06). With treatment, for both therapist- and self-guided patients, there was a significant improvement in drinking difficulties, cravings, and confidence with controlling cravings, as well as in anxiety, depression, and functional impairment. Further, the majority (75.7%) of patients completed five or more lessons, as well as reported overall satisfaction with the treatment (88.9%) and increased confidence in managing their symptoms (86.7%); these outcomes also did not differ between therapist- and self-guided patients.

CONCLUSIONS

The current study shows that ICBT for alcohol misuse is associated with reduced drinking and comorbid mental health difficulties over time, irrespective of whether patients chose to complete the course on their own or with therapist guidance.

TRIAL REGISTRATION NUMBER

NCT04611854 ( https://clinicaltrials.gov/ct2/show/NCT04611854 ).

A hybrid effectiveness-implementation trial of application-based tiered care (Mom's Good Mood) in treating perinatal anxiety within a primary health care system in China

INTRODUCTION

Perinatal anxiety (PNA) is a major public health concern.

METHODS

A hybrid effectiveness-implementation trial was conducted in two antenatal clinics in Hefei, China, to assess the effectiveness and cost-effectiveness of application-based tiered care (Mom's Good Mood, MGM) in treating PNA and to understand how well it fits into routine practices. Pregnant women who scored at least 5 points on the 7-Item Generalised Anxiety Disorder Scale (GAD-7) scale were successively assigned to the control group or the intervention group, which were given the usual care and MGM on usual care, respectively. At 6 months post partum, anxiety, depression and life satisfaction were assessed. Intention-to-treat analysis and the Reach, Effectiveness, Adoption, Implementation and Maintenance framework were adopted.

RESULTS

A total of 214 women were assigned to the control group and 341 to the intervention group. The mean changes in GAD-7 scores (Least-squares means, LSM, -1.42, 95% CI -2.18 to -0.66) and the risk of anxiety (adjusted odds ratio, aOR 0.30, 95% CI 0.18 to 0.51) were decreased, and the anxiety remission rate (aOR 2.72, 95% CI 1.69 to 4.40) were improved in the intervention group. Similar findings were observed regarding the change in Edinburgh Postnatal Depression Scale scores (LS -1.92, 95% CI -2.85 to -0.99), depression remission rate (aOR 2.24, 95% CI 1.39 to 3.63) and the risk of depression (aOR 0.57, 95% CI 0.33 to 0.98). MGM only costs ¥1.88 (US$0.27) per pregnant woman to boost the postpartum anxiety remission rate by 1% and was revealed to have a high reach rate of 78.3%, an adoption rate of 51.3%-80.8%.

CONCLUSION

MGM is a cost-effective and accessible tool in coping with PNA.

TRIAL REGISTRATION NUMBER

ChiCTR2100053419.

Digital interventions for reducing alcohol use in general populations: An updated systematic review and meta-analysis

This article updates a 2017 review on the effectiveness of digital interventions for reducing alcohol use in the general population. An updated systematic search of the MEDLINE database was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to identify randomized controlled trials (RCTs) published from January 2017 to June 2022 that evaluated the effectiveness of digital interventions compared with no interventions, minimal interventions, and face-to-face interventions aimed at reducing alcohol use in the general population and, that also reported changes in alcohol use (quantity, frequency, quantity per drinking day, heavy episodic drinking (HED), or alcohol use disorders identification test (AUDIT) scores). A secondary analysis was performed that analyzed data from RCTs conducted in students. The review was not preregistered. The search produced 2224 articles. A total of 80 studies were included in the review, 35 of which were published after the last systematic review. A total of 66, 20, 18, 26, and 9 studies assessed the impact of digital interventions on alcohol quantity, frequency, quantity per drinking day, HED, and AUDIT scores, respectively. Individuals randomized to the digital interventions drank 4.12 (95% confidence interval (CI): 2.88, 5.36) fewer grams of alcohol per day, had 0.17 (95% CI 0.06, 0.29) fewer drinking days per week, drank approximately 3.89 (95% CI: 0.40, 7.38) fewer grams of alcohol per drinking day, had 1.11 (95% CI: 0.32, 1.91) fewer HED occasions per month, and had an AUDIT score 3.04 points lower (95% CI: 2.23, 3.85) than individuals randomized to the control condition. Significant reductions in alcohol quantity, frequency, and HED, but not quantity per drinking day, were observed among students. Digital interventions show potential for reducing alcohol use in general populations and could be used widely at the population level to reduce alcohol-attributable harms.

Preferences of young adults on the development of a new digital add-on alcohol intervention for depression treatment: A qualitative study

AIM

To explore the preferences of young adults with regard to the development of a new digital add-on alcohol intervention to complement depression treatment.

METHODS

This qualitative study included young adults (18-35 years) with experience of either problematic alcohol use or depression or both (n = 29). Two rounds of focus groups were conducted, with two focus groups in each round. All focus groups were recorded, transcribed and analysed deductively and inductively on the basis of qualitative content analysis of the intervention type, features and design.

RESULTS

Young adults preferred a mobile health application with a clear and simple objective and navigation which was also accessible on a computer. With regard to intervention features, participants indicated a preference for in-depth, gain-framed information on alcohol use and a main feature enabling them to record their alcohol use and mood, which would be rewarded. Other preferences included personal goal-setting and monitoring, an activity list, experience stories, peer contact, guidance from experts by experience or volunteers and receiving notifications from the application. In terms of design, participants preferred short, animated videos and animation figure illustrations to complement written text. Moreover, participants rated the design of the intervention as highly important, yet very personal. Generally, participants preferred a light pastel colour scheme. Once again, participants indicated a need for a clear dashboard using pictograms to reduce the amount of text and fast, easy-to-use navigation.

CONCLUSION

The preferences indicated by young adults with regard to the intervention type, features and design may enhance the development of a new digital add-on alcohol intervention to complement depression treatment.

A Digital Health Intervention for Concussion: Development and Clinical Feasibility Study

BACKGROUND

Concussion is a common condition that can lead to a constellation of symptoms that affect quality of life, social integration, and return to work. There are several evidence-based behavioral and psychological interventions that have been found to improve postconcussion symptom burden. However, these are not routinely delivered, and individuals receive limited support during their concussion recovery.

OBJECTIVE

This study aimed to develop and test the feasibility of a digital health intervention using a systematic evidence-, theory-, and person-based approach.

METHODS

This was a mixed methodology study involving a scoping review (n=21), behavioral analysis, and logic model to inform the intervention design and content. During development, the intervention was optimized with feedback from individuals who had experienced concussions (n=12) and health care professionals (n=11). The intervention was then offered to patients presenting to the emergency department with a concussion (n=50). Participants used the intervention freely and input symptom data as part of the program. A number of outcome measures were obtained, including participant engagement with the intervention, postconcussion symptom burden, and attitudes toward the intervention. A selection of participants (n=15) took part in in-depth qualitative interviews to understand their attitudes toward the intervention and how to improve it.

RESULTS

Engagement with the intervention functionality was 90% (45/50) for the symptom diary, 62% (31/50) for sleep time setting, 56% (28/50) for the alcohol tracker, 48% (24/50) for exercise day setting, 34% (17/50) for the thought diary, and 32% (16/50) for the goal setter. Metrics indicated high levels of early engagement that trailed off throughout the course of the intervention, with an average daily completion rate of the symptom diary of 28.23% (494/1750). A quarter of the study participants (13/50, 26%) were classified as high engagers who interacted with all the functionalities within the intervention. Quantitative and qualitative feedback indicated a high level of usability and positive perception of the intervention. Daily symptom diaries (n=494) demonstrated a wide variation in individual participant symptom burden but a decline in average burden over time. For participants with Rivermead scores on completion of HeadOn, there was a strong positive correlation (r=0.86; P<.001) between their average daily HeadOn symptom diary score and their end-of-program Rivermead score. Insights from the interviews were then fed back into development to optimize the intervention and facilitate engagement.

CONCLUSIONS

Using this systematic approach, we developed a digital health intervention for individuals who have experienced a concussion that is designed to facilitate positive behavior change. Symptom data input as part of the intervention provided insights into postconcussion symptom burden and recovery trajectories.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05069948; https://clinicaltrials.gov/ct2/show/NCT05069948.

Psychological treatment of depression with other comorbid mental disorders: systematic review and meta-analysis

Most people with a mental disorder meet criteria for multiple disorders. We conducted a systematic review and meta-analysis of randomized trials comparing psychotherapies for people with depression and comorbid other mental disorders with non-active control conditions. We identified studies through an existing database of randomized trials on psychotherapies for depression. Thirty-five trials (3,157 patients) met inclusion criteria. Twenty-seven of the 41 interventions in the 35 trials (66%) were based on CBT. The overall effect on depression was large (g = 0.65; 95% CI: 0.40 ~ 0.90), with high heterogeneity (I² = 78%; 95% CI: 70 ~ 83). The ten studies in comorbid anxiety showed large effects on depression (g = 0.90; 95% CI: 0.30 ~ 1.51) and anxiety (g = 1.01; 95% CI: 0.28 ~ 1.74). For comorbid insomnia (11 comparisons) a large and significant effect on depression (g = 0.99; 95% CI: 0.16 ~ 1.82) and insomnia (g = 1.38; 95% CI: 0.38 ~ 2.38) were found. For comorbid substance use problems (12 comparisons) effects on depression (g = 0.25; 95% CI: 0.06 ~ 0.43) and on substance use problems (g = 0.25; 95% CI: 0.01 ~ 0.50) were significant. Most effects were no longer significant after adjustment for publication bias and when limited to studies with low risk of bias. Therapies are probably effective in the treatment of depression with comorbid anxiety, insomnia, and substance use problems.

Examining differential responses to the Take Care of Me trial: A latent class and moderation analysis

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Take Care of Me participants fell into three classes varying in risk.

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The low-risk class had the lowest pre-treatment symptom severity.

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The high-risk group had the highest symptom severity and executive dysfunction.

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Moderate risk individuals experienced the greatest benefits of the program.

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Future interventions may be tailored based on risk to maximize efficacy.

Given prevalent alcohol misuse-emotional comorbidities among young adults, we developed an internet-based integrated treatment called Take Care of Me. Although the treatment had an impact on several secondary outcomes, effects were not observed for the primary outcome. Therefore, the goal of the current study was to examine heterogeneity in treatment responses. The initial RCT randomized participants to either a treatment or psychoeducational control condition. We conducted an exploratory latent class analysis to distinguish individuals based on pre-treatment risk and then used moderated regressions to examine differential treatment responses based on class membership. We found evidence for three distinct groups. Most participants fell in the “low severity” group (n = 123), followed by the “moderate severity” group (n = 57) who had a higher likelihood of endorsing a previous mental health diagnosis and treatment and higher symptom severity than the low group. The “high severity” group (n = 42) endorsed a family history of alcoholism, and the highest symptom severity and executive dysfunction. Moderated regressions revealed significant class differences in treatment responses. In the treatment condition, high severity (relative to low) participants reported higher alcohol consumption and hazardous drinking and lower quality of life at follow-up, whereas moderate severity (relative to low) individuals had lower alcohol consumption at follow-up, and lower hazardous drinking at end-of-treatment. No class differences were found for participants in the control group. Higher risk individuals in the treatment condition had poorer responses to the program. Tailoring interventions to severity may be important to examine in future research.

Optimizing internet-delivered cognitive behaviour therapy for alcohol misuse—a randomized factorial trial examining effects of a pre-treatment assessment interview and guidance

Background

Internet-delivered cognitive behavioral therapy (ICBT) for alcohol misuse has potential to radically improve access to evidence-based care, and there is a need to investigate ways to optimize its delivery in clinical settings. Guidance from a clinician has previously been shown to improve drinking outcomes in ICBT, and some studies suggest that pre-treatment assessments may contribute in initiating early change. The objective of this study was to investigate the added and combined effects of a pre-treatment assessment interview and guidance on the outcomes of ICBT for alcohol misuse delivered in an online therapy clinic.

Methods

A 2X2 factorial randomized controlled trial was conducted where participants received access to an 8-week ICBT program, and either a pre-treatment assessment interview (Factor 1), guidance (Factor 2), a combination of these, or neither of these. Participants were 270 individuals (66.8% female, mean age = 46.5) scoring 8 or more on the Alcohol Use Disorders Identification Test and consuming 14 standard drinks or more in the preceding week. Primary outcomes were number of drinks consumed and number of heavy drinking days during the preceding week, 3 months post-treatment.

Results

Large within-group effects were found in terms of alcohol reductions (d_w ≥ 0.82, p < 0.001), but neither of the factors significantly improved drinking outcomes. Guidance was associated with greater adherence (i.e. completed modules).

Conclusions

Neither a pre-treatment assessment interview nor guidance from a clinician appears to improve drinking outcomes resulting from internet-delivered cognitive behaviour therapy for alcohol misuse when delivered in a routine online therapy clinic.

Trial registration: NCT03984786. Registered 13 June 2019, https://clinicaltrials.gov/ct2/show/NCT03984786

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00319-0.

Erste Erfahrungen mit einer Selbstmanagement-App in der stationären Suchtbehandlung

Zusammenfassung: Zielsetzung: Um die Möglichkeiten smartphonebasierter Interventionen für die stationäre Entwöhnungstherapie in einer Rehabilitationsklinik zu nutzen, wurde die MeinSalus-App entwickelt. Ziel der Studie ist es, (1) die Akzeptanz (Nutzungsabsicht) der App bei Patienten sowie beim therapeutischen Personal zu untersuchen, (2) Prädiktoren der Akzeptanz auf der Grundlage eines erweiterten UTAUT (Unified Theory of Acceptance and Use of Technology-)Modells zu bestimmen und (3) Aufschlüsse über das Nutzungsverhalten zu bekommen. Methodik: 193 von 282 stationären Patienten (68,4 %) sowie 18 von 34 Therapeuten (52,9 %) beantworteten Fragebögen zur Akzeptanz (Nutzungsabsicht) der App und deren einzelnen Funktionen, zu UTAUT- und mHealth-bezogenen Variablen sowie zu ihrem Nutzungsverhalten. Ergebnisse: Die mittlere Nutzungsabsicht (Range 1–5) für die App insgesamt lag für Patienten bei 4.65 ( SD = 0.83) und für Therapeuten bei 4.07 ( SD = 0.62). Alter, mobile Internetnutzung, erwarteter Nutzen sowie Vorbehalte gegenüber der App erwiesen sich als signifikante Prädiktoren der Akzeptanz. Beim Nutzungsverhalten ergab sich ein differenziertes Bild für die unterschiedlichen Funktionen. Schlussfolgerungen: Es zeigte sich sowohl in der Patientenstichprobe als auch beim teilnehmenden therapeutischen Personal eine hohe Akzeptanz der App, was auf eine akzeptable Grundlage für eine Implementierung in der stationären Suchtbehandlung hindeutet. Studien zu Effekten der App sollten sich anschließen.

Seeking care where they can: A systematic review of global trends in online alcohol treatment utilization among non-veteran and veteran women

Background

Findings from a person-level meta-analysis of online alcohol intervention trials suggest that women disproportionately seek out such interventions (Riper et al., 2018). Although women may be a "hidden population" that is particularly drawn to online alcohol interventions, trial design features may explain women's apparent over-representation in these trials.

Methods

This systematic review examined associations between gender-tailored recruitment/inclusion criteria and proportions of women enrolled in online alcohol intervention trials, evaluated whether community samples have greater proportions of women than clinical samples, and compared country-specific average proportions of women in trials to country-specific proportions of women with Alcohol Use Disorder (AUD).

Results

Forty-four trials met inclusion/exclusion criteria, 34 community samples and 10 drawn from clinical settings; 4 studies included U.S. veterans and were examined separately. The average proportion of community-recruited women across the studies was 51.20% and the average proportion of clinically-recruited women was 35.81%, a difference that was statistically significant. Across the countries with relevant trials, the expected proportion of those with AUD who are women is 27.1% (World Population Review, 2022). Only 2 studies used targeted recruitment for women so no between-group tests were conducted. There was not a statistically significant difference in the proportion of women across trials that did and did not use gender-tailored alcohol inclusion criteria.

Conclusions

Results from this systematic review suggest that study design factors do not account for the marked over-representation of women in online alcohol interventions, indicating that women are indeed a "hidden population" whose needs should be understood and accommodated.

Effectiveness of digital interventions for people with comorbid heavy drinking and depression: A systematic review and narrative synthesis

INTRODUCTION

Heavy drinking and depression frequently co-occur and make a substantial contribution to the global non-communicable disease burden. Positive evidence exists for the use of digital interventions with these conditions alone, but there has been limited assessment of combined approaches.

OBJECTIVE

A systematic review of the effectiveness of combined digital interventions for comorbid heavy drinking and major depression in community-dwelling populations.

METHODS AND ANALYSIS

Electronic databases were searched to October 2021 for randomised controlled trials that evaluated any personalised digital intervention for comorbid heavy drinking and depression. Primary outcomes were changes in quantity of alcohol consumed and depressive symptoms. Two reviewers independently assessed study eligibility, extracted data, and undertook risk of bias assessment. Due to the limited number and heterogeneity of studies identified, meta-analysis was not possible, therefore data were synthesised narratively.

RESULTS

Of 898 articles identified, 24 papers were reviewed in full, five of which met the inclusion criteria (N = 1503 participants). Three utilised web-based intervention delivery; two computer programmes delivered in a clinic setting. All involved multi-component interventions; treatment length varied from one to ten sessions. Four studies found no evidence for the superiority of combined digital interventions for comorbid heavy drinking and depression over therapist-delivered approaches, single condition interventions (including online), or assessment-only controls. Positive impacts of integrated online therapy compared to generalist online health advice were reported in a fifth study, but not maintained beyond the 1-month follow-up.

LIMITATIONS

Few eligible, heterogeneous studies prevented meta-analysis.

CONCLUSION

Limited evidence exists of the effectiveness of combined digital interventions for comorbid heavy drinking and depression in community dwelling populations.

Improving internet-delivered cognitive behaviour therapy for alcohol misuse: Patient perspectives following program completion

Although Internet-delivered cognitive behaviour therapy (ICBT) for alcohol misuse is efficacious in research trials, it is not routinely available in practice. Moreover, there is considerable variability in engagement and outcomes of ICBT for alcohol misuse across studies. The Alcohol Change Course (ACC) is an ICBT program that is offered free of charge by an online clinic in Saskatchewan, Canada, which seeks to fill this service gap, while also conducting research to direct future improvements of ICBT. As there is limited qualitative patient-oriented research designed to improve ICBT for alcohol misuse, in this study, we describe patient perceptions of the ACC post-treatment. Specifically, post-treatment feedback was obtained from 191 of 312 patients who enrolled in the ACC. Qualitative thematic analysis was used to examine post-treatment written comments related to what patients liked and disliked about the course, which skills were most helpful for them, and their suggestions for future patients. The majority of patients endorsed being very satisfied or satisfied with the course (n = 133, 69.6%) and 94.2% (n = 180) perceived the course as being worth their time. Worksheets (n = 61, 31.9%) and reflections of others (n = 40, 20.9%) received the most praise. Coping with cravings (n = 63, 33.0%), and identifying and managing risky situations (n = 46, 24.1%) were reported as the most helpful skills. Several suggestions for refining the course were provided with the most frequent recommendation being a desire for increased personal interaction (n = 24, 12.6%) followed by a desire for wanting more information (n = 22, 11.5%). Many patients offered advice for future ACC patients, including suggestions to make a commitment (n = 47, 24.6%), do all of the work (n = 29, 15.2%), and keep a consistent approach to the course (n = 24, 12.6%). The results provide valuable patient-oriented directions for improving ICBT for alcohol misuse.