The impact of guidance on Internet-based mental health interventions — A systematic review

Web-based intervention for young adults experiencing anxiety and hazardous alcohol use: Study protocol for an 18-month randomized controlled trial

BACKGROUND AND AIMS

Alcohol use and anxiety often co-occur, causing increased severity impairment. This protocol describes a randomized controlled trial (RCT) that aims to test the efficacy and cost-effectiveness of a web-based, self-guided alcohol and anxiety-focused program, compared with a web-based brief alcohol-focused program, for young adults who drink at hazardous levels and experience anxiety. It will also test moderators and mechanisms of change underlying the intervention effects.

DESIGN

This RCT will be conducted with a 1:1 parallel group.

SETTING

The study will be a web-based trial in Australia.

PARTICIPANTS

Individuals aged 17-30 years who drink alcohol at hazardous or greater levels and experience at least mild anxiety (n = 500) will be recruited through social media, media (TV, print) and community networks.

INTERVENTION AND COMPARATOR

Participants will be randomly allocated to receive a web-based, integrated alcohol-anxiety program plus technical and motivational telephone/e-mail support (intervention) or a web-based brief alcohol-feedback program (control).

MEASUREMENTS

Clinical measures will be assessed at baseline, post-intervention (2 months), 6 months (primary end-point), 12 months and 18 months. Co-primary outcomes are hazardous alcohol consumption and anxiety symptom severity. Secondary outcomes are binge-drinking frequency; alcohol-related consequences; depression symptoms; clinical diagnoses of alcohol use or anxiety disorder (at 6 months post-intervention), health-care service use, educational and employment outcomes; and quality of life. Mediators and moderators will also be assessed. Efficacy will be tested using mixed models for repeated measures within an intention-to-treat framework. The economic evaluation will analyze individual-level health and societal costs and outcomes of participants between each trial arm, while mediation models will test for mechanisms of change.

COMMENTS

This will be the first trial to test whether a developmentally targeted, web-based, integrated alcohol-anxiety intervention is effective in reducing hazardous alcohol use and anxiety severity among young adults. If successful, the integrated alcohol-anxiety program will provide an accessible intervention that can be widely disseminated to improve wellbeing of young adults, at minimal cost.

A scoping review of therapist behaviors in guided digital mental health interventions

Guided digital mental health interventions are more effective than unguided interventions. While research often emphasizes the frequency and intensity of guidance, less attention has been paid to the behaviors enacted by the therapists supporting clients using these interventions. A scoping review of the literature was conducted to systematically examine the evidence on therapist behaviors (i.e., the actions and feedback provided by supporters to patients). Applying broad eligibility criteria, a systematic search was conducted in PubMed, PsycInfo, the Cochrane Library, and Embase from their inception to January 1st 2024. Sixteen studies met inclusion criteria and were included in the review. Following data extraction, a descriptive analysis and synthesis of the results was performed. Most studies (n = 12; 75 %) focused on therapist behaviors in the context of internet-delivered Cognitive Behavioral Therapy for anxiety and depression. While earlier studies primarily focused on identifying therapist behaviors, later studies shifted towards examining the associations between therapist behaviors and different outcomes, as well as deriving research and clinical applications for improving guided internet-delivered treatments. Identified gaps and recommendations for clinical practice, research, training, and treatment development are discussed.

Developing a Guided Web App for Postpartum Depression Symptoms: User-Centered Design Approach

BACKGROUND

Psychological internet-based interventions have shown promise in preventing and treating perinatal depression, but their effectiveness can be hindered by low user engagement. This challenge often arises from a misalignment between technology attributes, user needs, and context. A user-centered, iterative approach involving all stakeholders is recommended.

OBJECTIVE

In this paper, we aimed to develop a user-friendly psychological internet-based intervention aimed at addressing the symptoms of perinatal depression through an iterative, user-centered approach.

METHODS

The development process followed the Center for eHealth Research and Disease Management Roadmap phases of contextual inquiry, value specification, and design. It involved a comprehensive literature review, 2 surveys, 10 focus groups, 5 usability interviews, and 1 technical pilot.

RESULTS

The contextual inquiry revealed a demand for accessible interventions for perinatal mental health, with internet-based solutions seen as viable options. Insights from the literature influenced intervention content and features. Stakeholders' openness to the intervention became evident during this phase, along with the integration of the first set of values. Initially, we assessed the broader perinatal context to identify the optimal period for the intervention. On the basis of the findings and practical considerations, we decided to specifically target postpartum depression symptoms. The value specification phase further defined the central values and translated them into requirements. In the design phase, feedback was obtained on the user experience of an early digital prototype and on the prototype's final version. The resulting intervention, named Mamá, te entiendo ("Mom, I get you"), is a guided web app based on cognitive behavioral therapy principles, integrating elements from attachment and mentalization theories. It aims to reduce depressive symptoms in women during the first months postpartum and consists of 6 core sequential modules, along with 3 additional modules, including 5 case examples illustrating depressive symptoms and therapeutic techniques. The intervention provides homework exercises and offers users the opportunity to receive feedback from an e-coach through the web app.

CONCLUSIONS

This study emphasizes the importance of a user-centered and iterative development process for psychological internet-based interventions. This process helps clarify user needs and provides valuable feedback on service design and quality, ultimately having the potential to enhance the utility and, presumably, the effectiveness of the intervention. The Discussion section shares valuable insights from the project, such as the value of the requirement sessions.

Impact of an Online Discussion Forum on Self-Guided Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Randomized Trial

BACKGROUND

Internet-delivered cognitive behavioral therapy (ICBT) is an effective and accessible treatment for various mental health concerns. ICBT has shown promising treatment outcomes among public safety personnel (PSP), who experience high rates of mental health problems and face barriers to accessing other mental health services. Client engagement and clinical outcomes are better in ICBT with therapist guidance, but ICBT is easier to implement on a large scale when it is self-guided. Therefore, it is important to identify strategies to improve outcomes and engagement in self-guided ICBT and other self-guided digital mental health interventions. One such strategy is the use of online discussion forums to provide ICBT clients with opportunities for mutual social support. Self-guided interventions accompanied by online discussion forums have shown excellent treatment outcomes, but there is a need for research experimentally testing the impact of online discussion forums in ICBT.

OBJECTIVE

We aimed to evaluate a transdiagnostic, self-guided ICBT intervention tailored specifically for PSP (which had not previously been assessed), assess the impact of adding a therapist-moderated online discussion forum on outcomes, and analyze participants' feedback to inform future research and implementation efforts.

METHODS

In this randomized trial, we randomly assigned participating PSP (N=107) to access an 8-week transdiagnostic, self-guided ICBT course with or without a built-in online discussion forum. Enrollment and participation were entirely web-based. We assessed changes in depression, anxiety, and posttraumatic stress as well as several secondary outcome measures (eg, treatment engagement and satisfaction) using questionnaires at the pre-enrollment, 8-week postenrollment, and 20-week postenrollment time points. Mixed methods analyses included multilevel modeling and qualitative content analysis.

RESULTS

Participants engaged minimally with the forum, creating 9 posts. There were no differences in treatment outcomes between participants who were randomly assigned to access the forum (56/107, 52.3%) and those who were not (51/107, 47.7%). Across conditions, participants who reported clinically significant symptoms during enrollment showed large and statistically significant reductions in symptoms (P<.05 and d>0.97 in all cases). Participants also showed good treatment engagement and satisfaction, with 43% (46/107) of participants fully completing the intervention during the course of the study and 96% (79/82) indicating that the intervention was worth their time.

CONCLUSIONS

Previous research has shown excellent clinical outcomes for self-guided ICBT accompanied by discussion forums and good engagement with those forums. Although clinical outcomes in our study were excellent across conditions, engagement with the forum was poor, in contrast to previous research. We discuss several possible interpretations of this finding (eg, related to the population under study or the design of the forum). Our findings highlight a need for more research evaluating the impact of online discussion forums and other strategies for improving outcomes and engagement in self-guided ICBT and other digital mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05145582; https://clinicaltrials.gov/study/NCT05145582.

[Internet-based self-help for loneliness-a systematic review]

BACKGROUND

Recently, the phenomenon of loneliness has received increasing attention. Loneliness is widespread and can have adverse consequences for mental and physical health if prolonged. Internet-based interventions (IBIs) for self-help have proven to be effective for a variety of psychological disorders. Due to several specific aspects, IBIs are also a relevant option for loneliness. This systematic review aims to present the current research on self-help IBIs for reducing loneliness.

METHODS

A systematic literature search was conducted in the databases Web of Science, PubMed, Scopus, PsycInfo, MedLine, PsycIndex, Cochrane Library and PsyArXiv between December 2023 and early January 2024. We included original German or English studies that addressed IBIs for self-help to reduce loneliness.

RESULTS

In total, eight studies published between 2017 and 2024 were included in the qualitative analysis. All studies were conducted in high-income countries, included predominantly well-educated female adults and were mostly satisfactory regarding their internal validity.

DISCUSSION

The results of this review suggest that self-help IBIs may be a promising option for alleviating loneliness. However, the work also points to the need for further research. Future studies should consider larger samples and people of different ages, genders and education levels in order to generalise the results of the present review.

Efficacy of digital mental health interventions for PTSD symptoms: A systematic review of meta-analyses

BACKGROUND

The present systematic review aimed to synthesize the results of meta-analyses which examine the effects of digital mental health interventions (DMHIs) on post-traumatic stress disorder (PTSD) symptoms, and investigate whether intervention characteristics (i.e., technique, timeframe, and therapeutic guidance) and methodological characteristics including outcome measures and sample inclusion criteria (age, gender, socioeconomic status, country, comorbidity) moderate the efficacy of digital interventions.

METHODS

A systematic search of various sources (ECSCOhost PsycInfo, PubMed, Web of Science, Scopus, EBSCOhost ERIC, Google Scholar, ProQuest Dissertations & Theses) including five peer-reviewed journals was conducted to identify relevant meta-analyses up to December 2023, and 11 meta-analyses were included in the final review.

RESULTS

Overall, our review elucidates that DMHIs are appropriate for alleviating PTSD symptoms in adults, with more consistent evidence supporting the efficacy of cognitive behavioral therapy (CBT)-based, compared to non-CBT-based, interventions when compared to control conditions. However, we found inconclusive evidence that the efficacy of DMHIs varied according to intervention timeframe, therapeutic guidance, or sample characteristics.

LIMITATIONS

A relatively limited number of different populations was sampled across meta-analyses. Further, while our review focused on PTSD symptoms to indicate the efficacy of digital interventions, other indices of effectiveness were not examined.

CONCLUSION

Our findings indicate the clinical utility of DMHIs for managing PTSD symptoms particularly when CBT-based intervention techniques are employed.

Intervention for school anxiety and absenteeism in children (ISAAC): Co-designing a brief parent-focused intervention for emotionally-based school avoidance

Emotionally-based school avoidance (EBSA) is an important driver of persistent school absenteeism and may have worsened in the context of COVID-19. This paper describes the development of a brief parent-focused psychosocial intervention with the goal to address the lack of accessible early interventions for EBSA. The developmental process used a person-based approach with two phases. In Phase 1, qualitative data were collected about intervention preferences and priorities from N = 10 parents and N = 7 practitioners in a series of co-design workshops. Phase 2 refined an intervention blueprint based on iterative consultations with N = 4 parents and N = 3 practitioners. Framework analysis was used to organise findings around key intervention parameters, including relevant mechanisms, content, and delivery methods needed to provide effective, acceptable and feasible support for families affected by EBSA. The resulting blueprint incorporates three online modules to be delivered over three weeks with each module consisting of psychoeducational videos, self-completed learning tasks and a corresponding coaching session. Respective module content includes: (i) self-care strategies to increase parent wellbeing and self-efficacy; (ii) parenting strategies to change behavioural patterns that maintain child distress and avoidance of school; and (iii) strategic communication strategies to increase the quality of home-school relationships. The blueprint has been developed into a full prototype for a forthcoming feasibility study.

Deep learning-based dimensional emotion recognition for conversational agent-based cognitive behavioral therapy

Internet-based cognitive behavioral therapy (iCBT) offers a scalable, cost-effective, accessible, and low-threshold form of psychotherapy. Recent advancements explored the use of conversational agents such as chatbots and voice assistants to enhance the delivery of iCBT. These agents can deliver iCBT-based exercises, recognize and track emotional states, assess therapy progress, convey empathy, and potentially predict long-term therapy outcome. However, existing systems predominantly utilize categorical approaches for emotional modeling, which can oversimplify the complexity of human emotional states. To address this, we developed a transformer-based model for dimensional text-based emotion recognition, fine-tuned with a novel, comprehensive dimensional emotion dataset comprising 75,503 samples. This model significantly outperforms existing state-of-the-art models in detecting the dimensions of valence, arousal, and dominance, achieving a Pearson correlation coefficient of r = 0.90, r = 0.77, and r = 0.64, respectively. Furthermore, a feasibility study involving 20 participants confirmed the model's technical effectiveness and its usability, acceptance, and empathic understanding in a conversational agent-based iCBT setting, marking a substantial improvement in personalized and effective therapy experiences.

A Self-Guided Internet-Based Intervention for the Reduction of Gambling Symptoms: A Randomized Clinical Trial

Importance

Most individuals with problem gambling or gambling disorder remain untreated due to barriers to treatment. Limited research exists on alternative treatments.

Objective

To investigate the efficacy of a self-guided internet-based intervention for individuals with gambling problems and to identify potential outcome moderators.

Design, Setting, and Participants

This single-center randomized clinical trial was conducted from July 13, 2021, to December 31, 2022, at the University Medical Center Hamburg-Eppendorf. Participants were recruited across Germany for 2 assessments (before intervention [t0] and 6 weeks after intervention [t1]). Eligible participants were individuals aged 18 to 75 years with gambling problems, internet access, German proficiency, and willingness to participate in 2 online assessments.

Intervention

The self-guided internet-based intervention was based on cognitive behavioral therapy, metacognitive training, acceptance and commitment therapy, and motivational interviewing.

Main Outcome and Measures

The primary outcome was change in gambling-related thoughts and behavior as measured with the pathological gambling adaption of the Yale-Brown Obsessive-Compulsive Scale. Secondary outcomes were change in depressive symptoms, gambling severity, gambling-specific dysfunctional thoughts, attitudes toward online interventions, treatment expectations, and patient satisfaction.

Results

A total of 243 participants (154 [63.4%] male; mean [SD] age, 34.73 [10.33] years) were randomized to an intervention group (n = 119) that gained access to a self-guided internet-based intervention during 6 weeks or a wait-listed control group (n = 124). Completion at t1 was high (191 [78.6%]). Results showed a significantly greater reduction in gambling-related thoughts and behavior (mean difference, -3.35; 95% CI, -4.79 to -1.91; P < .001; Cohen d = 0.59), depressive symptoms (mean difference, -1.05; 95% CI, -1.87 to -0.22; P = .01; Cohen d = 0.33), and gambling severity (mean difference, -1.46; 95% CI, -2.37 to -0.54; P = .002; Cohen d = 0.40) but not in gambling-specific dysfunctional thoughts (mean difference, -1.62; 95% CI, -3.40 to 0.15; P = .07; Cohen d = 0.23) favoring the intervention group. Individuals in the intervention group who had a positive treatment expectation and more severe gambling-specific dysfunctional thoughts and gambling symptoms benefited more on the primary outcome relative to the control group.

Conclusions and Relevance

In this randomized clinical trial, the effectiveness of a self-guided internet-based intervention for individuals with self-reported problematic gambling behavior was demonstrated when measured 6 weeks after start of the intervention. The study's findings are particularly relevant given the increasing need for accessible and scalable solutions to address problematic gambling.

Trial Registration

bfarm.de Identifier: DRKS00024840.

Guided web app intervention for reducing symptoms of depression in postpartum women: Results of a feasibility randomized controlled trial

Background

Chile faces a significant postpartum depression prevalence and treatment gap, necessitating accessible interventions. While cognitive-behavioral internet-based interventions have proven effective in high-income countries, this field is underdeveloped in Chile. Based on the country's widespread use of digital technology, a guided 8-week cognitive-behavioral web app intervention named "Mamá, te entiendo" was developed.

Objective

This study aimed to assess the acceptability and feasibility of "Mamá, te entiendo", for reducing depressive symptomatology in postpartum women.

Methods

Sixty-five postpartum women with minor or major depression were randomly assigned to either intervention or waitlist. Primary outcomes centered on study feasibility, intervention feasibility, and acceptability. Semi-structured interviews with a sub-sample enriched the understanding of participants' experiences. Secondary outcomes included mental health variables assessed at baseline, post-intervention, and 1-month follow-up.

Results

Chilean women displayed great interest in the intervention. 44.8 % of participants completed the intervention. Participants reported high satisfaction and engagement levels, with interviewees highlighting the value of the intervention's content, exercises, and therapist's feedback. However, preliminary efficacy analysis didn't reveal a significant interaction between group and time for outcome measures.

Discussion

This research represents a pioneering effort in Chile to evaluate an internet-based intervention for postpartum depression symptoms. The demonstrated feasibility and acceptability highlight the potential of integrating technology-driven approaches into mental health interventions. However, the intervention did not demonstrate superiority, as both groups exhibited similar positive progress in several outcomes. Therefore, the following research phase should involve a larger and more diverse sample to assess the intervention's effectiveness, identify influencing factors, and determine the individuals who benefit the most.

Outcomes of transdiagnostic internet-delivered cognitive behavioural therapy tailored to public safety personnel: A longitudinal observational study

First responders and other public safety personnel (PSP) experience high rates of mental health problems and face barriers to accessing mental healthcare. Internet-delivered cognitive behavioural therapy (ICBT) is an effective and accessible treatment for various mental health concerns. Canadian PSP report favorable attitudes toward ICBT, and preliminary outcomes demonstrate that they benefit from it. Expanding on this research, the current study consisted of a longitudinal observational study of 560 Canadian PSP who participated in ICBT. It was designed to assess the longer term effectiveness of ICBT and moderators of outcomes by gender, linguistic and occupational group, and years of occupational experience. We evaluated symptom change at 8, 26, and 52 weeks post-enrollment, and results among PSP who had elevated clinical scores, showed large reductions (Hedges' g) in symptoms of depression (g = 1.3), anxiety (g =1.48), posttraumatic stress (g =1.24), panic (g =1.19), and anger (g =1.07) and moderate reductions in symptoms of social anxiety (g =.48-.56). Moderator analyses revealed modest differences in pre-treatment symptoms among certain groups but no group differences in symptom change over time. Clients showed good completion of treatment materials and reported high treatment satisfaction. The results suggest further study of ICBT tailored to PSP is warranted, including evaluating ICBT tailored for PSP in other countries.

Outcomes of Best-Practice Guided Digital Mental Health Interventions for Youth and Young Adults with Emerging Symptoms: Part I. A Systematic Review of Socioemotional Outcomes and Recommendations

Youth-specific digital mental health interventions (DMHI) represent an emerging field of study, and aim to increase access, improve socioemotional outcomes, and, where required, support triage to targeted interventions. However, prior reviews have reported inconsistent findings on the clinical effectiveness of such interventions in young adults (12-25 years). Further, shortfalls remain for the impact of guided interventions based on the mode of delivery and the type of human support personnel (e.g., professional or peer) guiding the intervention. In response, this systematic review, co-designed with Australia's leading mental health organization, aims to assess the effectiveness of guided digital programs in improving youth socioemotional outcomes. Included studies involve young people experiencing mental ill-health, receiving brief (i.e., 1-12 sessions), digitally delivered (at least partially) psychological interventions that were guided or partially guided, tested in a type of experimental study, with a socioemotional outcome. Specific socioemotional outcomes examined were depression, anxiety, stress, wellbeing, mindfulness, and quality of life. A systematic search of the contemporary published and grey literature identified 22,482 records with 32 relevant records published between 2018 and 2023. A narrative synthesis guided integration of findings. Results demonstrated strong evidence for the effectiveness of guided interventions on socioemotional outcomes (i.e., depression, anxiety, stress) yet these effects were short-lived. When factoring in the use of different control groups (i.e., active vs. inactive), inconsistent effects were observed for the socioemotional outcomes of depression, anxiety, and stress. The mode of delivery (i.e., asynchronous, synchronous, combined) and the type of human support personnel did not appear to impact socioemotional outcomes. Results indicate efficacious brief digital interventions for depression and anxiety include refresher/follow-up content, goal setting content, and relapse prevention content. In contrast, poor efficacy is associated with interventions that include homework tasks, self-monitoring, and log-keeping content.PROSPERO, ID CRD42023405812.

Applying the Just-In-Time Adaptive Intervention Framework to the Development of Gambling Interventions

Just-In-Time Adaptive Interventions (JITAIs) are emerging "push" mHealth interventions that provide the right type, timing, and amount of support to address the dynamically-changing needs for each individual. Although JITAIs are well-suited to the delivery of interventions for the addictions, few are available to support gambling behaviour change. We therefore developed GamblingLess: In-The-Moment and Gambling Habit Hacker, two smartphone-delivered JITAIs that differ with respect to their target populations, theoretical underpinnings, and decision rules. We aim to describe the decisions, methods, and tools we used to design these two treatments, with a view to providing guidance to addiction researchers who wish to develop JITAIs in the future. Specifically, we describe how we applied a comprehensive, organising scientific framework to define the problem, define just-in-time in the context of the identified problem, and formulate the adaptation strategies. While JITAIs appear to be a promising design in addiction intervention science, we describe several key challenges that arose during development, particularly in relation to applying micro-randomised trials to their evaluation, and offer recommendations for future research. Issues including evaluation considerations, integrating on-demand intervention content, intervention optimisation, combining active and passive assessments, incorporating human facilitation, adding cost-effectiveness evaluations, and redevelopment as transdiagnostic interventions are discussed.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

The use of coaching in smartphone app-based cognitive behavioral therapy for body dysmorphic disorder

Background

Body dysmorphic disorder (BDD) is severe and undertreated. Digital mental health could be key to expanding access to evidence-based treatments, such as cognitive behavioral therapy for BDD (CBT-BDD). Coach guidance is posited to be essential for effective uptake of digital interventions. However, little is known about how different patients may use coaching, what patterns correspond to meaningful outcomes, and how to match coaching to patient needs.

Methods

Participants were 77 adults who received a 12-week guided smartphone CBT-BDD. Bachelor's-level coaches were available via asynchronous messaging. We analyzed the 400 messages sent by users to coaches during treatment. Message content was coded using the efficiency model of support (i.e., usability, engagement, fit, knowledge, and implementation). We aimed to clarify when and for what purposes patients with BDD used coaching, and if we can meaningfully classify patients by these patterns. We then assessed potential baseline predictors of coach usage, and whether distinct patterns relate to clinical outcomes.

Results

Users on average sent 5.88 messages (SD = 4.51, range 1-20) and received 9.84 (SD = 5.74, range 2-30). Regarding frequency of sending messages, latent profile analysis revealed three profiles, characterized by: (1) peak mid-treatment (16.88 %), (2) bimodal/more communication early and late in treatment (10.39 %), and (3) consistent low/no communication (72.73 %). Regarding content, four profiles emerged, characterized by mostly (1) engagement (51.95 %), (2) fit (15.58 %), (3) knowledge (15.58 %), and (4) miscellaneous/no messages (16.88 %). There was a significant relationship between frequency profile and age, such that the early/late peak group was older than the low communication group, and frequency profile and adherence, driven by the mid-treatment peak group completing more modules than the low contact group. Regarding content, the engagement and knowledge groups began treatment with more severe baseline symptoms than the fit group. Content profile was associated with dropout, suggesting higher dropout rates in the miscellaneous/no contact group and reduced rates in the engagement group. There was no relationship between profile membership and other outcomes.

Discussion

The majority of participants initiated little contact with their coach and the most common function of communications was to increase engagement. Results suggest that older individuals may prefer or require more support than younger counterparts early in treatment. Additionally, whereas individuals using coaching primarily for engagement may be at lower risk of dropping out, those who do not engage at all may be at elevated risk. Findings can support more personalized, data-driven coaching protocols and more efficient allocation of coaching resources.

The Use of Text Messaging as an Adjunct to Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder in Youth: Secondary Analysis

BACKGROUND

As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance.

OBJECTIVE

This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement.

METHODS

Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II).

RESULTS

Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (β=-0.029, 95% CI -0.11 to 0.048) and in each of the 3 categories: appreciating alliance (β=-0.096, 95% CI -0.80 to 0.61), alliance building disclosures (β=-0.098, 95% CI -0.28 to 0.084), and agreement confirmation (β=-0.076, 95% CI -0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement.

CONCLUSIONS

The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication.

TRIAL REGISTRATION

Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052.

The effectiveness of e-mental health interventions on stress, anxiety, and depression among healthcare professionals: a systematic review and meta-analysis

BACKGROUND

Many healthcare professionals are experiencing psychological distress. Electronic mental health (e-mental health) interventions are convenient and multifunctional. This review aimed to examine the effectiveness of e-mental health interventions in enhancing the well-being of healthcare professionals and to identify moderating factors.

METHODS

A comprehensive and systematic retrieval of randomized controlled trial (RCT) studies was conducted across eight databases. Population, intervention, comparison, and outcome (PICO) were used to define eligibility criteria. Stress, anxiety, and depression were included as the main outcomes. The overall effect was calculated based on the random effect model, and the effect size was presented using the standardized mean difference. The characteristics of the research design, intervention object, and intervention design were further selected as potential moderating factors for subgroup analysis. Meta-regression analyses were finally performed, incorporating intervention duration and sample size as independent variables.

RESULTS

A total of 20 studies were included in the systematic review, and 17 were included in the meta-analysis. A large effect on relieving stress and anxiety and a small-to-medium effect on reducing depression were observed. Subgroup analyses showed that features including mindfulness approaches, online courses, computer use, group interventions, and professional guidance were more favorable in the design of services. Meta-regression revealed that intervention duration only affected anxiety symptoms. Caution should be exercised, as some subgroups had fewer studies and higher heterogeneity. For the secondary outcomes, a large effect on emotional exhaustion and a small-to-medium effect on well-being were observed.

CONCLUSION

In general, e-mental health interventions significantly improve the psychological health of healthcare staff. Future high-quality, large-scale studies targeting healthcare professionals and specific intervention scenarios are warranted.

Refining Parent SMART: User feedback to optimize a multi-modal intervention

INTRODUCTION

The continuing care period following residential substance use treatment is a time when adolescents are at especially high risk for relapse, yet few families engage in traditional office-based care. Parent SMART (Substance Misuse among Adolescents in Residential Treatment) is a multi-component continuing care intervention for parents that combines three digital health technologies - an "off the shelf" online parenting program, daily phone notifications, and an online parent networking forum - with support from a parent coach. The current study solicited both qualitative and quantitative user feedback about Parent SMART to ensure responsivity to user preferences, refinement, and continuous improvement of the intervention.

METHODS

Exit interviews were conducted with 30 parents who received Parent SMART, which includes (1) a parent networking forum; (2) daily text messages reminders of skills, (3) an "off-the-shelf" online parenting program; and (4) in-person or telehealth parent coaching sessions. The study collected qualitative feedback using semi-structured interviews and obtained quantitative feedback via a series of ratings of each Parent SMART component on a 5-point Likert scale administered at each follow-up assessment.

RESULTS

Quantitative feedback suggest that parents rated all four elements of Parent SMART as easy to use. Qualitative feedback revealed that parents valued several aspects of Parent SMART including the brevity and structure of the intervention elements, the reminders to use parenting skills, and the sense of social connectedness fostered by different components. Recommended refinements included a number of strategies to enhance personalization and ease of navigation.

CONCLUSIONS

Parent feedback informed enhancements to the Parent SMART intervention prior to implementation in a larger, ongoing pragmatic effectiveness trial. The current study serves as a model for applying a staged person-centered approach and eliciting both quantitative and qualitative feedback to refine digital health technologies.

Effects of a Serious Game for Adolescent Mental Health on Cognitive Vulnerability: Pilot Usability Study

Background

Adolescent mental health is of utmost importance. E-mental health interventions, and serious games in particular, are appealing to adolescents and can have beneficial effects on their mental health. A serious game aimed at improving cognitive vulnerability (ie, beliefs or attitudes), which can predispose an individual to mental health problems, can contribute to the prevention of these problems in adolescents.

Objective

This study aimed to assess the feasibility of the prototype of a serious game called "Silver."

Methods

The prototype of the serious game was developed using a user-centered participatory design. The prototype of Silver focused on 1 aspect of a serious game for improving cognitive vulnerability in adolescents, that is, the recognition and identification of cognitive distortions. Through the game, players were required to identify and classify the character's thoughts as helpful or unhelpful. Upon successful advancement to the next level, the task becomes more challenging, as players must also identify specific types of cognitive distortions. A pre- and posttest uncontrolled design was used to evaluate the game, with a 1-week intervention phase in which participants were asked to play the game. Participants aged 12-16 years were recruited in schools. The outcomes of interest were the recognition of cognitive distortions and presence of participants' cognitive distortions. The game was also evaluated on its effects, content, and usefulness.

Results

A total of 630 adolescents played Silver and completed the assessments. Adolescents were significantly better at recognizing cognitive distortions at the pretest (mean 13.09, SD 4.08) compared to the posttest (mean 13.82, SD 5.09; t629=-4.00, P<.001). Furthermore, their cognitive distortions decreased significantly at the posttest (mean 38.73, SD 12.79) compared to the pretest (mean 41.43, SD 10.90; t629=7.98, P<.001). Participants also indicated that the game helped them recognize cognitive distortions. Many participants considered the game appealing (294/610, 48.2%) but boring (317/610, 52%) and preferred a more comprehensive game (299/610, 49%).

Conclusions

Findings from this study suggest that a serious game may be an effective tool for improving cognitive vulnerability in adolescents. The development of such a serious game, based on the prototype, is recommended. It may be an important and innovative tool for the universal prevention of mental health problems in adolescents. Future research on the effects of the game is warranted.

Clinical effects of online cognitive behavioral group therapy for chronic pain patients and developing a therapeutic alliance: A pre-post pilot trial

Background and Aims

Research suggests that various psychosocial factors influence chronic pain, with psychotherapies like cognitive behavioral therapy  proving effective. However, the limited availability and accessibility have prolonged suffering among patients with chronic pain. This challenge has led to a growing demand for accessible online interventions. We developed an online cognitive behavioral group therapy (CBGT) program, building upon our existing face-to-face CBGT program. We compared the scores obtained by patients during the treatment-as-usual (TAU) period with those collected at the beginning and at the end of the intervention.

Methods

Patients with chronic pain (N = 22) agreed to participate in the online CBGT program, which was conducted once a week for 12 sessions. The sample size was decided based on the effect sizes of our past face-to-face CBGT. We assessed pain intensity [Visual Analogue Scale (VAS)], pain catastrophizing [pain catastrophizing scale (PCS)] and psychiatric assessment [Beck Depression Inventory-Second Edition (BDI)-II], State-Trait-Anxiety Inventory (STAI), and Short Form Health Survey (SF-36) at three points: entry, pretreatment, and posttreatment. We also evaluated the participants' therapeutic alliance with the treatment staff [short-form version of the Working Alliance Inventory (WAI-S)]. We utilized analyses of variance, Friedman test, paired t-tests, Wilcoxon signed-rank test, and Pearson correlation analysis for data evaluation.

Results

Results indicated a significant posttreatment improvement in VAS, PCS, and BDI-II scores compared to the TAU period. Furthermore, posttreatment WAI-S scores increased significantly compared to pretreatment scores. Also, positive correlations were observed among pre- and posttreatment changes in WAI-S, pain intensity, and pain catastrophizing scores.

Conclusion

There is a possibility that a therapeutic alliance can be established, and therapeutic effects achieved through an online CBGT intervention; however, additional research is required to substantiate this potential. We have registered this clinical trial in UMIN-CTR on 04/21/2021 with the number UMIN000043982.

Efficacy of an Internet- and Mobile-Based Intervention for Subclinical Anxiety and Depression (ICare Prevent) with Two Guidance Formats: Results from a Three-Armed Randomized Controlled Trial

INTRODUCTION

Limited research exists on intervention efficacy for comorbid subclinical anxiety and depressive disorders, despite their common co-occurrence. Internet- and mobile-based interventions (IMIs) are promising to reach individuals facing subclinical symptoms.

OBJECTIVE

This study aimed to evaluate the efficacy of a transdiagnostic and self-tailored IMI in reducing subclinical anxiety and depressive symptom severity with either individualized (IG-IMI) or automated (AG-IMI) guidance compared to a waitlist control group with care-as-usual access (WLC).

METHODS

Participants included 566 adults with subclinical anxiety (GAD-7 ≥ 5) and/or depressive (CES-D ≥16) symptoms, who did not meet criteria for a full-syndrome depressive or anxiety disorder. In a three-arm randomized clinical trial, participants were randomized to a cognitive behavioral 7-session IMI plus booster session with IG-IMI (n = 186) or AG-IMI (n = 189) or WLC (n = 191). Primary outcomes included observer-rated anxiety (HAM-A) and depressive (QIDS) symptom severity 8 weeks after randomization assessed by blinded raters via telephone. Follow-up outcomes at 6 and 12 months are reported.

RESULTS

Symptom severity was significantly lower with small to medium effects in IG-IMI (anxiety: d = 0.45, depression: d = 0.43) and AG-IMI (anxiety: d = 0.31, depression: d = 0.32) compared to WLC. No significant differences emerged between guidance formats in primary outcomes. There was a significant effect in HAM-A after 6 months favoring AG-IMI. On average, participants completed 85.38% of IG-IMI and 77.38% of AG-IMI.

CONCLUSIONS

A transdiagnostic, self-tailored IMI can reduce subclinical anxiety and depressive symptom severity, but 12-month long-term effects were absent. Automated guidance holds promise for enhancing the scalability of IMIs in broad prevention initiatives.

Interpersonal factors in internet-based cognitive behavioral therapy for depression: Attachment style and alliance with the program and with the therapist

Objective This open-trial study examined effects of a culturally-adapted Hebrew version of guided internet-based cognitive behavioural therapy (ICBT) for depression. We examined therapeutic alliance with the therapist and with the programme (content) as potential predictors of outcomes. Furthermore, we examined whether anxious and avoidant attachment styles improved, although relationships were not the focus of treatment. Method: We examined alliance with therapist and alliance with programme and their time-lagged (1 week), longitudinal relationship with depression outcomes, and change in anxious and avoidant attachment during treatment. Results: Depression and insomnia improved significantly (Cohen's d: depression = 1.34, insomnia = 0.86), though dropout was relatively high (49%). Alliance with programme and with the therapist predicted adherence and dropout, whereas only alliance with therapist predicted symptom improvement. Avoidant attachment decreased over treatment whereas anxious attachment did not. Conclusion: A culturally-adapted version of ICBT for depression showed that alliance with therapist and alliance with programme both can play an important role in its effectiveness: alliance with programme and the therapist drive adherence and dropout and alliance with therapist is related to symptom improvement. Although the focus of treatment is not interpersonal, avoidant attachment style can improve following ICBT.

A Self-Guided Web-Based App (MyDiaMate) for Enhancing Mental Health in Adults With Type 1 Diabetes: Insights From a Real-World Study in the Netherlands

BACKGROUND

MyDiaMate is a web-based intervention specifically designed for adults with type 1 diabetes (T1D) that aims to help them improve and maintain their mental health. Prior pilot-testing of MyDiaMate verified its acceptability, feasibility, and usability.

OBJECTIVE

This study aimed to investigate the real-world uptake and usage of MyDiaMate in the Netherlands.

METHODS

Between March 2021 and December 2022, MyDiaMate was made freely available to Dutch adults with T1D. Usage (participation and completion rates of the modules) was tracked using log data. Users could volunteer to participate in the user profile study, which required filling out a set of baseline questionnaires. The usage of study participants was examined separately for participants scoring above and below the cutoffs of the "Problem Areas in Diabetes" (PAID-11) questionnaire (diabetes distress), the "World Health Organization Well-being Index" (WHO-5) questionnaire (emotional well-being), and the fatigue severity subscale of the "Checklist Individual Strength" (CIS) questionnaire (fatigue). Two months after creating an account, study participants received an evaluation questionnaire to provide us with feedback.

RESULTS

In total, 1008 adults created a MyDiaMate account, of whom 343 (34%) participated in the user profile study. The mean age was 43 (SD 14.9; 18-76) years. Most participants were female (n=217, 63.3%) and higher educated (n=198, 57.6%). The majority had been living with T1D for over 5 years (n=241, 73.5%). Of the study participants, 59.1% (n=199) of them reported low emotional well-being (WHO-5 score≤50), 70.9% (n=239) of them reported elevated diabetes distress (PAID-11 score≥18), and 52.4% (n=178) of them reported severe fatigue (CIS score≥35). Participation rates varied between 9.5% (n=19) for social environment to 100% (n=726) for diabetes in balance, which opened by default. Completion rates ranged from 4.3% (n=1) for energy, an extensive cognitive behavioral therapy module, to 68.6% (n=24) for the shorter module on hypos. There were no differences in terms of participation and completion rates of the modules between study participants with a more severe profile, that is, lower emotional well-being, greater diabetes distress, or more fatigue symptoms, and those with a less severe profile. Further, no technical problems were reported, and various suggestions were made by study participants to improve the application, suggesting a need for more personalization.

CONCLUSIONS

Data from this naturalistic study demonstrated the potential of MyDiaMate as a self-help tool for adults with T1D, supplementary to ongoing diabetes care, to improve healthy coping with diabetes and mental health. Future research is needed to explore engagement strategies and test the efficacy of MyDiaMate in a randomized controlled trial.

Cognitive Behavioral Digital Interventions are Effective in Reducing Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis

Anxiety disorders are the most prevalent mental health issues in childhood, yet most children do not receive treatment. With recent advances in technology, a growing number of digital anxiety interventions are becoming accessible. This study is the first meta-analysis to evaluate the effectiveness and usefulness of digital cognitive-behavioral anxiety interventions for individuals under the age of 18. Five electronic databases (PsycNET, Web of Science, Science Direct, Pub Med, SAGE Journals.) were systematically searched in 2021. Inclusion criteria were: randomized control trials with a wait list no treatment control, standalone to blended care with minimal therapist involvement, diagnosed anxiety disorder or elevated levels of anxiety, outcome anxiety levels had to be assessed by a clinician, or the patients themselves by a validated anxiety measure. We assessed and controlled for publication bias, and considered the risk of bias using the Cochrane risk-of-bias tool. Eighteen studies were found eligible, which examined 1290 participants in total. Pooled effect sizes using a random-effects model yielded low overall effect for self-ratings (g = 0.28, k = 18, p < 0.001, 95% CI [0.14; 0.41]), and medium effect for ratings of clinicians (g = 0.66, k = 13, p < 0.001, 95% CI [0.50; 0.80]) as well as for parental report (g = 0.49, k = 16, p < 0.001, 95% CI [0.29; 0.69]). We found that the effects were homogenous across studies. Further examining potential moderating factors of treatment efficacy is needed in future research, as well as conducting studies that compare traditional methods of care to their digital counterparts. Digital interventions could contribute to the well-being of children regardless of age, minimizing therapist involvement. We conclude that digital cognitive-behavioral interventions may provide an accessible, cost-effective, and scalable anxiety treatment option for children and adolescents.

Association between expectations and clinical outcomes in online v. face-to-face therapy - an individual participant data meta-analysis

BACKGROUND

Online treatments are increasing in number and are currently available for a wide range of clinical problems. To date little is known about the role of treatment expectations and other placebo-like mechanisms in online settings compared to traditional face-to-face treatment. To address this knowledge gap, we analyzed individual participant data from randomized clinical trials that compared online and face-to-face psychological interventions.

METHODS

MEDLINE (Ovid) and PsycINFO (Ovid) were last searched on 2 February 2021. Randomized clinical trials of therapist guided online v. face-to-face psychological interventions for psychiatric or somatic conditions using a randomized controlled design were included. Titles, abstracts, and full texts of studies were independently screened by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Authors of the matching trials were contacted for individual participant data. Ratings from the Credibility and Expectancy Questionnaire and the primary outcome measure from each trial were used to estimate the association between expectation ratings and treatment outcomes in online v. face-to-face interventions, using a mixed-effects model.

RESULTS

Of 7045 screened studies, 62 full-text articles were retrieved whereof six studies fulfilled the criteria and provided individual participant data (n = 491). Overall, CEQ ratings predicted clinical outcomes (β = 0.27) at end of treatment with no moderating effect of treatment modality (online v. face-to-face).

CONCLUSIONS

Online treatment appears to be equally susceptible to expectancy effects as face-to-face therapy. This furthers our understanding of the importance of placebo-like factors in online treatment and may aid the improvement of healthcare in online settings.

Development and experiences of an internet-based acceptance and commitment training (I-ACT) intervention in ice hockey players: a qualitative feasibility study

Internet-based psychological interventions have increased the accessibility of evidence-based treatments in clinical psychology but are still an unexplored delivery format in sport psychology research. This study describes the development and evaluates the experiences of an internet-based acceptance and commitment therapy/training (I-ACT) intervention in ice hockey players focusing on performance enhancement and a sustainable sport participation. I-ACT consisted of seven weekly modules and the feasibility of the intervention was investigated using a qualitative research design. Four national level ice hockey players took part of I-ACT and were interviewed about their experiences using a semi-structured protocol. Interview transcripts were analyzed using qualitative content analysis. Findings suggest that the content of I-ACT was comprehensible, relevant, and that it was possible to put the psychological skills into practice. I-ACT was described as helpful to the ice hockey players either in their sport performance or in their life outside of sport. The internet-format was generally perceived as positive, flexible, and a feasible option for delivering psychological interventions in an elite sport context. Some concerns were raised regarding the timing of the intervention at the end of the season, and some players also wished for more time to complete I-ACT. It was also expressed that some of the exercises could have been better adapted for goaltenders. Further trials are needed to evaluate the effects of I-ACT on performance and mental health outcomes in various sport populations using robust quantitative research methodology. Internet-based psychological interventions are a potential future opportunity to make evidence-based practices more accessible for athletes.

Efficacy of an Internet-based self-help intervention with human guidance or automated messages to alleviate loneliness: a three-armed randomized controlled trial

Loneliness is a prevalent and stigmatized phenomenon associated with adverse (mental) health outcomes. However, evidence-based interventions to alleviate loneliness are scarce. This randomized controlled trial (ClinicalTrials.gov-ID: NCT04655196) evaluated the efficacy of an internet-based cognitive behavioral self-help intervention (ICBT) to reduce loneliness by comparing two intervention groups with guidance or automated messages against a waitlist control group. Adults (N = 243) suffering from loneliness were recruited from the general public and then randomly assigned (2:2:1) to a 10-week ICBT with human guidance (GU) or automated messages (AM) or to a waitlist control group (WL). Loneliness, assessed with the UCLA-9, was the primary outcome. Outcomes were assessed at baseline and 10 weeks (post) and analyzed using mixed-effects models. The pooled intervention conditions resulted in lower loneliness scores at post-assessment than the WL (Cohen's d = 0.57, 95% CI [0.25; 0.89]) and reduced depressive symptoms, social anxiety, social avoidance behavior, and rejection sensitivity (d = 0.32-0.52). The GU group had lower loneliness scores at post-assessment than the AM group (d = 0.42, 95% CI [0.13; 0.70]). ICBT effectively alleviated loneliness, and guidance increased the reduction in loneliness compared to automated messages. Alleviating loneliness with ICBT further seems to reduce the overall burden of psychopathological symptoms.

A Web-Based Tool to Assess Social Inclusion and Support Care Planning in Mental Health Supported Accommodation: Development and Preliminary Test Study

BACKGROUND

Individuals with severe mental illness living in supported accommodation are often socially excluded. Social inclusion is an important aspect of recovery-based practice and quality of life. The Social Inclusion Questionnaire User Experience (SInQUE) is a measure of social inclusion that has been validated for use with people with mental health problems. Previous research has suggested that the SInQUE could also help support care planning focused on enabling social inclusion in routine mental health practice.

OBJECTIVE

This study aims to develop a web-based version of the SInQUE for use in mental health supported accommodation services, examine its acceptability and perceived usefulness as a tool to support care planning with service users, determine the extent of uptake of the tool in supported accommodation settings, and develop a program theory and logic model for the online SInQUE.

METHODS

This study involved a laboratory-testing stage to assess the acceptability of the SInQUE tool through "think-aloud" testing with 6 supported accommodation staff members and a field-testing stage to assess the acceptability, utility, and use of the SInQUE tool over a 5-month period. An implementation strategy was used in 1 London borough to encourage the use of the SInQUE. Qualitative interviews with 12 service users and 12 staff members who used the tool were conducted and analyzed using thematic analysis. The use of the SInQUE was compared with that in 2 other local authority areas, 1 urban and 1 rural, where the tool was made available for use but no implementation strategy was used.

RESULTS

Overall, 17 staff members used the SInQUE with 28 different service users during the implementation period (approximately 10% of all service users living in supported accommodation in the study area). The staff and service users interviewed felt that the SInQUE was collaborative, comprehensive, user-friendly, and relevant. Although some staff were concerned that particular questions might be too personal, service users did not echo this view. Participants generally felt that the SInQUE could help identify individuals' priorities regarding different aspects of social inclusion by prompting in-depth conversations and tailoring specific support to address service users' inclusion goals. Some interviewees also suggested that the tool could highlight areas of unmet or unmeetable needs across the borough that could feed into service planning. The SInQUE was not used in the comparison areas that had no implementation strategy.

CONCLUSIONS

The online SInQUE is an acceptable and potentially useful tool that can be recommended to assess and support care planning to enable social inclusion of people living in mental health supported accommodation services. Despite this, uptake rates were modest during the study period. A concerted implementation strategy is key to embedding its use in usual care, including proactive endorsement by senior leaders and service managers.

Layperson-Supported, Web-Delivered Cognitive Behavioral Therapy for Depression in Older Adults: Randomized Controlled Trial

BACKGROUND

Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative.

OBJECTIVE

This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program's impact on secondary psychosocial outcomes and explore potential change mechanisms.

METHODS

Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences.

RESULTS

Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=-0.68, 95% CI -1.00 to -0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size.

CONCLUSIONS

Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/44210.

Resilience strengthening in youth with a chronic medical condition: a randomized controlled feasibility trial of a combined app and coaching program

Youth with a chronic medical condition (CMC) are often affected by comorbid mental disorders. Resilience-strengthening interventions can protect youth's mental health, yet evidence-based programs remain scarce. To address this lack, this study aimed to evaluate the feasibility of a dual approach combining app-based resilience training and cognitive behavioral group coaching. Fifty-one youths with CMC treated at a German university children's hospital aged 12-16 years were recruited. They were randomly assigned to a combined app game and coaching intervention or sole app gameplay. At pre-, post-intervention, and at a 2-month follow-up resilience, automatic negative thoughts and an app and coaching evaluation were assessed. Feasibility was defined as a recruitment rate of 70%, an 85% adherence rate for the REThink game, and 70% participation in both coaching sessions. Feasibility criteria were reached for coaching participation but not for recruitment or app adherence. While both the REThink game app and coaching intervention had high acceptance rates among youth with CMC, participants receiving additional coaching sessions showed higher satisfaction and adherence rates. Participants preferred remote to in-person meetings. The findings support a combination of a gamification app approach with online group coaching. Group coaching can improve adherence while online options increase accessibility. Future research should focus on testing in diverse participant samples, language, and age-adapted updates of the REThink game app. These findings provide guidance for increasing adherence in future intervention studies in youth with CMC cohorts.

Effects on voice hearing distress and social functioning of unguided application of a smartphone app - A randomized controlled trial

Background

Temstem is a smartphone app developed with and for clinical voice hearing individuals with the aim to reduce their voice hearing distress and improve social functioning.

Methods

A randomized controlled trial with adult outpatients suffering from distressing and frequent auditory verbal hallucinations (AVH) was conducted. Participants were randomized to unguided 'Temstem+AVH monitoring' or unguided 'AVH monitoring only' (control condition). Assessments were performed at baseline, post-intervention (week 5-6), and follow-up (week 9-10). Primary outcomes were voice hearing distress and social functioning, as measured with Experience Sampling Method (ESM), consisting of multiple daily questionnaires during six days. In addition, voices and mood were self-monitored with help of a daily reflective questionnaire. Analyses were linear regression models (intention-to-treat).

Results

44 Participants were allocated to Temstem and 45 to the control condition. No significant differences between the groups were found on both primary outcomes.

Conclusion

Our results do not support the effectiveness of stand-alone use of Temstem versus symptom monitoring on voice hearing distress or social functioning in voice hearing individuals. In order to potentially improve effectiveness of an mHealth tool in a population of people with frequent and distressing voices, we recommend to involve persons with lived experience in all stages of development and research; to thoroughly test the (technological) usability before performing an RCT; to test whether guidance of a therapist is needed to optimize effectiveness; and to provide prompts to remind the user to actually use the tool.

Development and evaluation of an internet- and mobile-based intervention for individualized return to work planning after inpatient rehabilitation - Study protocol for a randomized-controlled-trial

Background

Following discharge, it is crucial for patients to transfer intentions and action plans from inpatient rehabilitation into everyday life. This ensures their reintegration into social and working life and prevents economic costs due to sick leave or reduced earning capacity pension. However, most established aftercare programs do not specifically address occupational problems or challenges during occupational measures such as graded return to work. The aim of this study is to evaluate the efficacy of the low-threshold online self-help intervention marena (Meine Arbeitsbezogene Reha-Nachsorge - My Work-related Rehabilitation Aftercare) to support return to work.

Methods

A two-arm randomized-controlled-trial (RCT) will be conducted. A total of N = 400 rehabilitation inpatients across different indication areas (psychosomatic, orthopedic, or cardiologic) aged 18 to 65 years with a planned return to work after medical rehabilitation, have a heightened social-medical risk and private internet access and are insured with the German Pension insurance or statutory health insurance, will be recruited in four medical and psychosomatic clinics in Germany. Participants will be allocated to either the intervention (IG) or the control group (CG). In a stepped-care model, participants of the IG will receive access to the non-guided internet- and mobile-based intervention marena (IG subgroup 1) or marena in combination with GSA-Online plus (IG subgroup 2), a guided psychodynamic internet-based intervention that has proven effective in two trials regarding occupational and health objectives. Based on a priori defined indication criteria, clinic staff will recommend either IG subgroup 1 or IG subgroup 2. The CG will receive optimized treatment as usual with access to a survey feature within marena. The primary outcome will be work status after 6 months (T2) and 12 months (T4). The endpoint at 12 months (T4) after discharge from inpatient rehabilitation will be considered as secondary endpoint. Work status is defined as positive if the participant is working and has ≤ 6 weeks of sick leave at T2 and ≤ 12 weeks of sick leave at T4. Secondary outcomes include successful completion of graded return to work, successful application for benefits for participation in working life, current work ability, social-medical risk, subjective prognosis of future employment, quality of life, somatic symptoms, coping, social support, depression, anxiety, and psychosocial stress.

Discussion

This study will contribute to the evidence concerning efficacy of online aftercare interventions. If proven efficacious, marena could provide an individualized and adaptable self-help approach to promote return to work following inpatient rehabilitation.

Internet-based cognitive behavioural therapy in the real world: Naturalistic use and effectiveness of an evidence-based platform in New Zealand

OBJECTIVE

Internet-based cognitive behavioural therapy (iCBT) is an efficacious, scalable intervention that could help meet the significant demand for psychological treatment. Yet, there is limited real-world evidence for its effectiveness. This study investigated the use and effectiveness of a free iCBT programme ('Just a Thought') in New Zealand.

METHODS

We analysed 18 months of user data from the Just a Thought website to understand the characteristics of those who used the Depression and Generalised Anxiety Disorder courses, how many lessons they completed, how mental distress changed across each course and the factors associated with adherence and improvement in mental health.

RESULTS

The results for both courses followed very similar patterns. Course adherence was low overall. There were small differences in adherence by age, gender and ethnicity, and larger differences for those who were 'prescribed' Just a Thought by a healthcare worker. Mixed models showed significant reductions in mental distress, with some tapering of improvement across latter lessons. Those most likely to show clinically meaningful reductions in mental distress had completed more lessons, were older and had a higher baseline level of distress.

CONCLUSION

Alongside previous efficacy research, this real-world data indicate that iCBT is most likely to be effective at the population level and across different subgroups if users complete as much of the course as possible. Strategies to increase course adherence and maximise the public health benefits of iCBT include healthcare workers 'prescribing' iCBT and tailored solutions to meet the needs of young people, Māori and Pasifika.

A pilot study of the perceptions and acceptability of guidance using artificial intelligence in internet cognitive behaviour therapy for perfectionism in young people

Perfectionism is a transdiagnostic process associated with a range of psychological disorders. Cognitive Behaviour Therapy for Perfectionism (CBT-P) has been demonstrated as efficacious across guided and unguided internet delivered interventions in reducing perfectionism and psychopathology. The aim of this pilot study was to understand perceptions and acceptability of an artificial intelligence supplemented CBT-P intervention (AI-CBT-P) in young people with lived experience of anxiety and depression (n = 8; age range 19-29 years, M = 24 years, SD = 3.77; 50 % female, 38 % male, 12 % non-binary). Young people reported that they were frequent users of artificial intelligence for study, work and general information, were positive about the intervention and using artificial intelligence for guidance in a self-help intervention, but also noted several concerns. Young people perceived numerous benefits to AI-CBT-P, including ease of access, low cost, lack of stigma and benefits for individuals with social anxiety. Overall, young people appear to be interested in, and have a positive view of, AI-CBT-P. Further research is now required to examine the feasibility and acceptability of the intervention.

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: Randomized Controlled Trial

BACKGROUND

Dental phobia (DP) and injection phobia (IP) are common in children and adolescents and are considered some of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. As the availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking.

OBJECTIVE

This randomized controlled trial tests whether therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP or IP to receive dental treatment.

METHODS

We enrolled 33 participants (mean age 11.2, SD 1.9 y) whom a clinical psychologist had diagnosed with DP, IP, or both. After inclusion, participants were randomized to either ICBT (17/33, 52%) or a control group of children on a waitlist (16/33, 48%). ICBT was based on exposure therapy and comprised a 12-week at-home program combined with visits to their regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and 1 parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the outcome variables before treatment start and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview with a clinical psychologist. Our primary outcome measure was the Picture-Guided Behavioral Avoidance Test (PG-BAT), which assesses the ability to approach 17 dental clinical procedures, and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self-efficacy and levels of dental and injection anxiety. The children and their parents completed the questionnaires.

RESULTS

All participants underwent the 12-week follow-up. After treatment, 41% (7/17) of the participants in the ICBT group no longer met the diagnostic criteria for DP or IP, whereas all participants in the control group did (P=.004). Repeated-measure ANOVAs showed that ICBT led to greater improvements on the PG-BAT compared with the control group; between-group effect sizes for the Cohen d were 1.6 (P<.001) for the child-rated PG-BAT and 1.0 (P=.009) for the parent-rated PG-BAT. Reductions in our secondary outcomes-dental fear and anxiety (P<.001), negative cognitions (P=.001), and injection fear (P=.011)-as well as improvements in self-efficacy (P<.001), were all significantly greater among children in the ICBT group than in the controls. No participants reported adverse events.

CONCLUSIONS

ICBT seems to be an effective treatment for DP and IP in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; this therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02588079; https://clinicaltrials.gov/study/NCT02588079.

The Evaluation of the GET.ON Nationwide Web-Only Treatment Service for Depression- and Stress-Related Symptoms: Naturalistic Trial

BACKGROUND

GET.ON (HelloBetter) treatment interventions have been shown to be efficacious in multiple randomized controlled trials.

OBJECTIVE

This study evaluated the effectiveness of 2 GET.ON interventions, GET.ON Mood Enhancer and GET.ON Stress, in a national digital mental health service implemented across Germany.

METHODS

Following an initial web-based questionnaire, participants were allocated to either intervention based on their baseline symptom severity and personal choice and received a semistandardized guided, feedback-on-demand guided, or self-guided version of the treatment. Uncontrolled routine care data from 851 participants were analyzed using a pretest-posttest design. Half of the participants (461/851, 54.2%) were allocated to the stress intervention (189/461, 41% semistandardized; 240/461, 52% feedback on demand; and 32/461, 6.9% self-guided), and almost all participants in the mood intervention (349/352, 99.2%) received semistandardized guidance.

RESULTS

Results on depression-related symptom severity indicated a reduction in reported symptoms, with a large effect size of d=-0.92 (95% CI -1.21 to -0.63). Results on perceived stress and insomnia indicated a reduction in symptom severity, with large effect sizes of d=1.02 (95% CI -1.46 to -0.58) and d=-0.75 (95% CI -1.10 to -0.40), respectively. A small percentage of participants experienced deterioration in depression-related symptoms (11/289, 3.8%), perceived stress (6/296, 2%), and insomnia (5/252, 2%). After completing treatment, 51.9% (150/289) of participants showed a clinically reliable change in depression-related symptoms, whereas 20.4% (59/289) achieved a close to symptom-free status. Similar improvements were observed in perceived stress and insomnia severity. Guidance moderated the effectiveness of and adherence to the interventions in reducing depressive symptom severity. Effect sizes on depression-related symptom severity were d=-1.20 (95% CI -1.45 to -0.93) for the semistandardized group, d=-0.36 (95% CI -0.68 to -0.04) for the feedback-on-demand group, and d=-0.83 (95% CI -1.03 to -0.63) for the self-guided group. Furthermore, 47.6% (405/851) of the participants completed all modules of the intervention. Participant satisfaction was high across all patient groups and both interventions; 89.3% (242/271) of participants would recommend it to a friend in need of similar help. Limitations include the assignment to treatments and guidance formats based on symptom severity. Furthermore, part of the differences in symptom change between groups must be assumed to be due to this baseline difference in the measures.

CONCLUSIONS

Future digital health implementation and routine care research should focus on monitoring symptom deterioration and other negative effects, as well as possible predictors of deterioration and the investigation of individual patient trajectories. In conclusion, this study supports the effectiveness of tailored digital mental health services in routine care for depression- and stress-related symptoms in Germany. The results highlight the importance of guidance in delivering internet-based cognitive behavioral therapy interventions and provide further evidence for its potential delivered as web-only solutions for increasing access to and use of psychological treatments.

An app-based training for adolescents with problematic digital-media use and their parents (Res@t digital): protocol for a cluster-randomized clinical trial

Background

Digital media-use disorders (DMUD) in adolescents are a rising phenomenon associated with psychological distress, comorbid mental disorders, and high burden on affected families. Since the ICD-11 introduced criteria for gaming disorder, these can now be transferred to describe additional DMUD associated with social media platforms and streaming services. Most evidence for effective treatments comes from cognitive-behavioral therapy (CBT). However, interventions based on theoretical models for adolescents and their parents are widely missing, leading to a significant clinical gap.

Methods

Res@t digital (Resource-Strengthening Training for Adolescents with Problematic Digital-Media Use and their Parents) is the app-based translation of the first model-based digital intervention for adolescents with DMUD and their parents based on CBT. It comprises separate but content-related modules for adolescents (Res@t-A) and parents (Res@t-P), applying multimodal techniques. The effectiveness of Res@t will be evaluated within a multicenter cluster-randomized controlled evaluator-blinded pre-post follow-up trial with the waitlist control group (CG). In addition to the Res@t program in the intervention group, both groups will receive treatment as usual within primary child and adolescent psychiatric/psychotherapeutic healthcare. The primary outcome addresses DMUD symptom reduction after 10 weeks. Secondary outcomes are related to a reduction in psychological and family-related problems and an increase in parental self-efficacy. All outcomes will be assessed using standardized self-report measures. A total of 1,334 participating adolescent-parent dyads from a large clinical network throughout Germany are planned to be included in the primary analyses based on an intention-to-treat approach, applying linear mixed models.

Discussion

Assuming superiority of Res@t over the control condition, the intervention has the potential to provide evidence-based treatment for a significant number of help-seeking families, supporting local healthcare structures and resources. It is a promising program for practicable implementation and flexible use in different settings.

Clinical trial registration

https://drks.de, DRKS00031043.

Treating child anxiety using family-based internet delivered cognitive behavior therapy with brief therapist guidance: A randomized controlled trial

Online treatment delivery has the potential to increase access to evidence-based mental health care for children with anxiety disorders. Using a randomized controlled trial design, we evaluated the efficacy of Cool Kids Online, a family-based and therapist supported internet-delivered cognitive behavioral treatment (CBT) designed to target anxiety disorders in children. Ninety-five children aged 7-12 years with a DSM-5 anxiety disorder were randomly allocated to Cool Kids Online or a waitlist control. Children were assessed at baseline, week 11, and 6-months following treatment. Children in waitlist received treatment after week 11 and also completed assessments immediately and six months after treatment, allowing treatment maintenance to be evaluated for all children. Compared to waitlist, Cool Kids Online led to significantly greater remission of anxiety disorders (primary and all anxiety diagnoses) and greater reduction of caregiver-reported anxiety symptoms and interference at week 11. Child-reported anxiety symptoms and interference and child- and caregiver-reported depressive or externalizing symptoms did not differ significantly between conditions. Medium to large within-treatment effects were observed for all children from pre to post treatment with post treatment effects maintained until follow-up. Overall, the findings provide support for the efficacy of the program in treating anxiety. Cool Kids Online compared to waitlist for the remission of anxiety disorders in clinically anxious children; anzctr.org.au; ACTRN12615000947505.

A pilot randomised controlled trial exploring the feasibility and efficacy of a human-AI sleep coaching model for improving sleep among university students

Objective

Sleep quality is a crucial concern, particularly among youth. The integration of health coaching with question-answering (QA) systems presents the potential to foster behavioural changes and enhance health outcomes. This study proposes a novel human-AI sleep coaching model, combining health coaching by peers and a QA system, and assesses its feasibility and efficacy in improving university students' sleep quality.

Methods

In a four-week unblinded pilot randomised controlled trial, 59 university students (mean age: 21.9; 64% males) were randomly assigned to the intervention (health coaching and QA system; n = 30) or the control conditions (QA system; n = 29). Outcomes included efficacy of the intervention on sleep quality (Pittsburgh Sleep Quality Index; PSQI), objective and self-reported sleep measures (obtained from Fitbit and sleep diaries) and feasibility of the study procedures and the intervention.

Results

Analysis revealed no significant differences in sleep quality (PSQI) between intervention and control groups (adjusted mean difference = -0.51, 95% CI: [-1.55-0.77], p = 0.40). The intervention group demonstrated significant improvements in Fitbit measures of total sleep time (adjusted mean difference = 32.5, 95% CI: [5.9-59.1], p = 0.02) and time in bed (adjusted mean difference = 32.3, 95% CI: [2.7-61.9], p = 0.03) compared to the control group, although other sleep measures were insignificant. Adherence was high, with the majority of the intervention group attending all health coaching sessions. Most participants completed baseline and post-intervention self-report measures, all diary entries, and consistently wore Fitbits during sleep.

Conclusions

The proposed model showed improvements in specific sleep measures for university students and the feasibility of the study procedures and intervention. Future research may extend the intervention period to see substantive sleep quality improvements.

Dataset size versus homogeneity: A machine learning study on pooling intervention data in e-mental health dropout predictions

Objective

This study proposes a way of increasing dataset sizes for machine learning tasks in Internet-based Cognitive Behavioral Therapy through pooling interventions. To this end, it (1) examines similarities in user behavior and symptom data among online interventions for patients with depression, social anxiety, and panic disorder and (2) explores whether these similarities suffice to allow for pooling the data together, resulting in more training data when prediction intervention dropout.

Methods

A total of 6418 routine care patients from the Internet Psychiatry in Stockholm are analyzed using (1) clustering and (2) dropout prediction models. For the latter, prediction models trained on each individual intervention's data are compared to those trained on all three interventions pooled into one dataset. To investigate if results vary with dataset size, the prediction is repeated using small and medium dataset sizes.

Results

The clustering analysis identified three distinct groups that are almost equally spread across interventions and are instead characterized by different activity levels. In eight out of nine settings investigated, pooling the data improves prediction results compared to models trained on a single intervention dataset. It is further confirmed that models trained on small datasets are more likely to overestimate prediction results.

Conclusion

The study reveals similar patterns of patients with depression, social anxiety, and panic disorder regarding online activity and intervention dropout. As such, this work offers pooling different interventions' data as a possible approach to counter the problem of small dataset sizes in psychological research.

Guided versus non-guided digital psychological interventions for cancer patients: A systematic review and meta-analysis of engagement and efficacy

OBJECTIVE

To evaluate engagement with and efficacy of guided versus non-guided digital interventions targeting psychological symptoms of cancer via a systematic review of current evidence.

METHODS

PubMed, Scopus, PsychINFO, MEDLINE, and CINAHL databases were searched. Eligible publications were randomised controlled trials of guided or non-guided digital psychological interventions used in cancer settings reporting intervention efficacy and/or engagement. Study methodological quality was assessed using the Cochrane risk of bias (RoB) tool. Random effects meta-analyses were performed on outcomes with sufficient data, with sub-group analyses of intervention type and follow-up period.

RESULTS

Forty-three studies were included. Studies varied by level of guidance, type of technology used, duration, and outcomes assessed. Most studies had a high overall RoB. Meta-analysis indicated that guided interventions significantly reduced distress, anxiety, and fatigue, while non-guided did not. For depression and quality of life, both guided and non-guided interventions produced significant improvements. Guided interventions reported higher levels of intervention engagement than non-guided.

CONCLUSIONS

Guided digital psychological interventions were likely to be more effective than non-guided ones for cancer patients, particularly in reducing distress, anxiety, and fatigue. Whilst both types were found to improve depression and life quality, guided interventions were associated with higher patient engagement. These findings suggest digital interventions could supplement traditional cancer care, warranting further research concerning long-term effects and cost-efficiency.

Brief digital self-care intervention for health anxiety in a Swedish Medical University Clinic: a prospective single-group feasibility study

OBJECTIVES

In routine psychiatric care in Stockholm, Sweden, a comprehensive therapist-guided intervention for clinically significant health anxiety is implemented. However, there is a need for more easily accessible self-care interventions to improve treatment dissemination. This study aimed to transform an existing therapist-guided digital intervention into a self-care intervention, reducing patient burden and used clinical resources while maintaining quality and safety.

DESIGN

An uncontrolled feasibility study.

SETTING

Conducted at Karolinska Institutet, a medical university in Sweden, with nationwide recruitment trough online advertisements.

PARTICIPANTS

Twenty-five adults used the self-care intervention and underwent telephone assessments, along with completing self-rated questionnaires.

INTERVENTION

The newly developed 8-week self-care intervention was designed to be user-friendly without therapist guidance, and to facilitate high levels of behavioural engagement.

PRIMARY AND SECONDARY OUTCOME MEASURES

Indicators of quality and safety, including changes in health anxiety severity (primary), clinician time, participant adherence, perceived credibility/satisfaction with the intervention and adverse events, were benchmarked against a previous study of the more comprehensive intervention it was based on.

RESULTS

Compared with the original guided intervention, the self-care intervention was condensed in terms of text (up to 70% less reading), duration (8 weeks instead of 12) and number of exercises. Quality indicators were similar to the original version. Most participants worked actively with core components in the self-care intervention. Within-group effects on health anxiety from pretreatment to the 3-month follow-up were large (g=1.37; 95% CI 0.74 to 2.00). No serious adverse events were reported.

CONCLUSIONS

This brief digital self-care intervention shows potential for increasing access to treatment for individuals with health anxiety while reducing the burden on patients and clinical resources. Future studies should investigate the optimal type of intervention and support for different individuals, and if non-inferiority can be established.

TRIAL REGISTRATION NUMBER

NCT05446766.

Self-Management Analysis in Chronic Conditions (SMACC) checklist: an international consensus-based tool to develop, compare and evaluate self-management support programmes

OBJECTIVES

The Self-Management Analysis in Chronic Conditions (SMACC) checklist was developed as a guidance tool to support the development, comparison and evaluation of self-management support programmes for persons with a chronic condition. The checklist was based on a previously performed concept analysis of self-management. The aim of this study was to validate its content using an international Delphi study and to deliver a final version.

DESIGN

A two-round Delphi study was conducted between October 2022 and January 2023. Using the researchers' networks, professionals with research or clinical expertise in self-management support and chronic conditions were recruited via online purposive snowball sampling. Participants were asked to score each item of the checklist (16 items total) on 3 content validity indicators: (1) clarity and comprehensibility, (2) relevance and importance and (3) degree of alignment with the overall goal of the checklist to promote adequate and comprehensive self-management support programmes. A consensus threshold of 75% agreement was used. The participants were also asked general questions about the checklist as a whole and were asked to provide feedback considering its refinement.

RESULTS

Fifty-four professionals with an average 14.5 years of experience participated in round 1, 48 with an average 12.5 years of experience participated in round 2. The majority of professionals were from Western Europe. For the majority of items consensus was reached after round 1. In round 2, 3 of the 4 remaining items reached consensus, 1 last item was retained based on highly recurring feedback.

CONCLUSIONS

The SMACC checklist was considered a valid and comprehensive tool to aid the development, evaluation and comparison of self-management support programmes. It was acknowledged as a useful instrument to supplement existing frameworks and was seen as feasible to implement in both research and clinical settings. Further validation in the field, with input from patients and peer experts, will be valuable.

Internet-delivered therapist-assisted cognitive behavioral therapy for gambling disorder: a randomized controlled trial

Objectives

Cognitive behavioral therapy (CBT) is the most promising treatment for gambling disorder (GD) but only 21% of those with problematic gambling seek treatment. CBT over the Internet might be one way to reach a larger population. The aim of this study was to assess the effectiveness of Internet-delivered CBT with therapist guidance compared to an active control treatment.

Methods

Using a single-blinded design, 71 treatment-seeking gamblers (18-75 years) diagnosed with GD were randomized to 8 weeks of Internet-delivered CBT guided by telephone support, or 8 weeks of Internet-delivered motivational enhancement paired with motivational interviewing via telephone (IMI). The primary outcome was gambling symptoms measured at a first face-to-face assessment, baseline (treatment start), every 2 weeks, post-treatment, and 6-month follow-up. Gambling expenditures, time spent gambling, depression, anxiety, cognitive distortions, and quality of life were assessed as secondary outcomes. Analysis was performed on the full analysis sample (n = 60), with intention-to-treat sensitivity analyses (n = 69).

Results

In the CBT group, 80% stayed in treatment until the final week, compared to 67% in IMI. Post-treatment and at 6-month follow-up, no differences were found between CBT and IMI for any outcome measure. An exploratory analysis of the total sample (n = 60) showed a significant effect of time during treatment on gambling symptoms (d, [95% CI] 0.52, [-1.15, 2.02]) and all secondary outcomes except the gambling diary (depression (0.89, [-1.07-2.65]); anxiety (0.69, [-1.20-2.38])); cognitive distortions (0.84, [-0.73-2.29]); quality of life (0.60, [-0.61-1.70])). Post-treatment, there were no clinical gambling symptoms in either group. Some deterioration was seen between post-treatment and 6-month follow-up on gambling symptoms (0.42, [-1.74-2.43]), depression (0.59, [-0.82-1.86]), and anxiety (0.30, [-0.99-1.48]). Additionally, it was observed that the largest reduction in gambling symptoms was between the first assessment and baseline.

Conclusion

Both treatments offered in this study were effective at reducing gambling symptoms. It is also possible that the process of change started before treatment, which gives promise to low-intensity interventions for GD. Additional research is needed as this approach could be both cost-effective and has the potential to reach more patients in need of treatment than is currently possible.

Clinical trial registration

https://www.isrctn.com/, identifier ISRCTN38692394.

Effectiveness of holistic mobile health interventions on diet, and physical, and mental health outcomes: a systematic review and meta-analysis

Background

Good physical and mental health are essential for healthy ageing. Holistic mobile health (mHealth) interventions-including at least three components: physical activity, diet, and mental health-could support both physical and mental health and be scaled to the population level. This review aims to describe the characteristics of holistic mHealth interventions and their effects on related behavioural and health outcomes among adults from the general population.

Methods

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, China National Knowledge Infrastructure, and Google Scholar (first 200 records). The initial search covered January 1, 2011, to April 13, 2022, and an updated search extended from April 13, 2022 to August 30, 2023. Randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) were included if they (i) were delivered via mHealth technologies, (ii) included content on physical activity, diet, and mental health, and (iii) targeted adults (≥18 years old) from the general population or those at risk of non-communicable diseases (NCDs) or mental disorders. Studies were excluded if they targeted pregnant women (due to distinct physiological responses), individuals with pre-existing NCDs or mental disorders (to emphasise prevention), or primarily utilised web, email, or structured phone support (to focus on mobile technologies without exclusive human support). Data (summary data from published reports) extraction and risk-of-bias assessment were completed by two reviewers using a standard template and Cochrane risk-of-bias tools, respectively. Narrative syntheses were conducted for all studies, and random-effects models were used in the meta-analyses to estimate the pooled effect of interventions for outcomes with comparable data in the RCTs. The study was registered in PROSPERO, CRD42022315166.

Findings

After screening 5488 identified records, 34 studies (25 RCTs and 9 pre-post NRSIs) reported in 43 articles with 5691 participants (mean age 39 years, SD 12.5) were included. Most (91.2%, n = 31/34) were conducted in high-income countries. The median intervention duration was 3 months, and only 23.5% (n = 8/34) of studies reported follow-up data. Mobile applications, short-message services, and mobile device-compatible websites were the most common mHealth delivery modes; 47.1% (n = 16/34) studies used multiple mHealth delivery modes. Of 15 studies reporting on weight change, 9 showed significant reductions (6 targeted on individuals with overweight or obesity), and in 10 studies reporting perceived stress levels, 4 found significant reductions (all targeted on general adults). In the meta-analysis, holistic mHealth interventions were associated with significant weight loss (9 RCTs; mean difference -1.70 kg, 95% CI -2.45 to -0.95; I2 = 89.00%) and a significant reduction in perceived stress levels (6 RCTs; standardised mean difference [SMD] -0.32; 95% CI -0.52 to -0.12; I2 = 14.52%). There were no significant intervention effects on self-reported moderate-to-vigorous physical activity (5 RCTs; SMD 0.21; 95%CI -0.25 to 0.67; I2 = 74.28%) or diet quality scores (5 RCTs; SMD 0.21; 95%CI -0.47 to 0.65; I2 = 62.27%). All NRSIs were labelled as having a serious risk of bias overall; 56% (n = 14/25) of RCTs were classified as having some concerns, and the others as having a high risk of bias.

Interpretation

Findings from identified studies suggest that holistic mHealth interventions may aid reductions in weight and in perceived stress levels, with small to medium effect sizes. The observed effects on diet quality scores and self-reported moderate-to-vigorous physical activity were less clear and require more research. High-quality RCTs with longer follow-up durations are needed to provide more robust evidence. To promote population health, future research should focus on vulnerable populations and those in middle- and low-income countries. Optimal combinations of delivery modes and components to improve efficacy and sustain long-term effects should also be explored.

Funding

National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise (CREATE) Programme and Physical Activity and Nutrition Determinants in Asia (PANDA) Research Programme.

An ACT self-help intervention for adults with a visible difference in appearance: A pilot feasibility and acceptability randomized controlled study

Individuals living with a visible difference in appearance experience high levels of social anxiety, yet self-help interventions for this heterogeneous population are not available. We conducted a pilot trial of a novel Acceptance and Commitment Therapy (ACT) based self-help intervention.Individuals with anxiety about having a visible difference in appearance (n = 284) were randomized to an ACT-based four-week intervention (n = 145) or a waitlist control condition (n = 139). We collected pre and follow-up (four-weeks after the completion of the intervention) data. Primary outcomes included social anxiety and impairments in functioning. Psychological flexibility (PF) was also examined. ANCOVAs, controlling for pre scores, indicated significant improvements in functioning by the intervention group. No significant differences were observed for anxiety and PF between conditions at follow-up. Drop out was 68% for the intervention and 41% for the control group, with no differences in the groups in age, origin, gender, or type of visible difference. Participants in the intervention group found the intervention almost equally, useful (77%) and helpful (73%). An ACT-based self-help intervention can alleviate distress related to visible difference in appearance. More sophisticated designs are needed now, to collect idiographic and longitudinal data and examine personalized changes across time in this population.

Online coaching blended couple-oriented intervention for preventing depression among Korean middle adulthood: A feasibility study

Depression and marital satisfaction have a reciprocal cause-and-effect relationship. Thus, couple relationships should be considered to maximize the effectiveness of couple-oriented interventions for depression. Moreover, developing culturally tailored couple-oriented interventions is critical for improving cultural acceptability and enhancing the perceived effectiveness of the interventions. A new culturally tailored MindGuide Couple intervention was developed to prevent Korean middle adulthood depression and enhance couple relationships using intervention mapping. This feasibility study used a single-arm, pre- and post-test, and 2-month follow-up design to explore the reach, acceptability, and preliminary effectiveness of this preventive intervention. Reach was assessed by recruitment, retention, and completion rates; acceptability was measured based on helpfulness, suitability, and satisfaction; and preliminary effectiveness was measured by depression (CES-D), positive and negative affect (PANAS), satisfaction with life (SWLS), couple satisfaction (CSI), and healthy relationship between spouses (FRAS). Fifteen middle-aged couples participated in four psychoeducational and asynchronous online modules and four synchronous coaching sessions via videoconferencing for 5-7 weeks. Data were analyzed using descriptive statistics and repeated measures with analysis of variance. With a 94.1% completion rate, the participants demonstrated high satisfaction with the online coaching blended intervention and reported that it was helpful and easy to use. Both husbands and wives showed significant differences over time in depression, couple satisfaction, and healthy relationships between spouses. This feasibility study demonstrated the successful reach, acceptability, and potential effectiveness of this preventive intervention. Additionally, we suggest the importance of culturally tailored and online coaching blended couple-oriented intervention for preventing depression and promoting healthy couple relationships.

Finding the Best Match - a Case Study on the (Text-)Feature and Model Choice in Digital Mental Health Interventions

With the need for psychological help long exceeding the supply, finding ways of scaling, and better allocating mental health support is a necessity. This paper contributes by investigating how to best predict intervention dropout and failure to allow for a need-based adaptation of treatment. We systematically compare the predictive power of different text representation methods (metadata, TF-IDF, sentiment and topic analysis, and word embeddings) in combination with supplementary numerical inputs (socio-demographic, evaluation, and closed-question data). Additionally, we address the research gap of which ML model types - ranging from linear to sophisticated deep learning models - are best suited for different features and outcome variables. To this end, we analyze nearly 16.000 open-text answers from 849 German-speaking users in a Digital Mental Health Intervention (DMHI) for stress. Our research proves that - contrary to previous findings - there is great promise in using neural network approaches on DMHI text data. We propose a task-specific LSTM-based model architecture to tackle the challenge of long input sequences and thereby demonstrate the potential of word embeddings (AUC scores of up to 0.7) for predictions in DMHIs. Despite the relatively small data set, sequential deep learning models, on average, outperform simpler features such as metadata and bag-of-words approaches when predicting dropout. The conclusion is that user-generated text of the first two sessions carries predictive power regarding patients' dropout and intervention failure risk. Furthermore, the match between the sophistication of features and models needs to be closely considered to optimize results, and additional non-text features increase prediction results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41666-023-00148-z.

Tailored internet-based psychological treatment for psychological problems during the COVID-19 pandemic: A randomized controlled trial

The COVID-19 pandemic influence mental health in both infected and non-infected populations. In this study we examined if individually tailored internet-based cognitive behavioral therapy (ICBT) could be an effective treatment for psychological symptoms related to the pandemic. Following recruitment we included 76 participants who were randomized to either a treatment group (n = 37) or a waitlist control group (n = 39). The treatment group received 8 modules (out of 16 possible) during 8 weeks with weekly therapist support. We collected data on symptoms of depression, experienced quality of life, anxiety, stress, anger, insomnia, PTSD, and alcohol use before, after the treatment and at one year follow-up. Using multiple regression analysis, group condition was found to be a statistically significant predictor for a decrease, favoring the treatment group, in symptoms of depression, insomnia, and anger with small to moderate effect sizes. The improvements remained at one year follow-up. Group condition did not significantly predict changing symptoms regarding experienced quality of life, anxiety, stress, PTSD and alcohol use. Findings indicate that ICBT is an effective intervention for some psychological symptoms associated with the COVID-19 pandemic. There is a need for further studies on mechanisms of change and on tailored ICBT for problems associated with crises like the pandemic.