Preventing depression: Qualitatively examining the benefits of depression-focused iCBT for participants who do not meet clinical thresholds

Dropout or Drop-In Experiences in an Internet-Delivered Intervention to Prevent Depression and Enhance Subjective Well-Being During the Perinatal Period: Qualitative Study

Background

The perinatal period is a vulnerable time when women are at increased risk of depression. "Mamma Mia" is a universal preventive internet-delivered intervention offered to pregnant women, with the primary goals of preventing the onset or worsening of depression and enhancing subjective well-being during the perinatal period. However, treatment dropout from internet-delivered interventions is often reported.

Objective

The study aim was to acquire an understanding of the different experiences among participants who dropped out of the Mamma Mia intervention during pregnancy, compared to participants who dropped out during the postpartum follow-up phase.

Methods

A total of 16 women from a larger randomized controlled trial (Mamma Mia) participated in individual semistructured interviews following a strengths, weaknesses, opportunities, and threats format. Of the 16 participants included, 8 (50%) women dropped out early from the intervention during pregnancy (pregnancy group), whereas 8 (50%) women dropped out later, after giving birth (postpartum follow-up group). Data were analyzed using the framework approach.

Results

The results showed that there were differences between the groups. In general, more participants in the postpartum follow-up group reported that the program was user-friendly. They became more aware of their own thoughts and feelings and perceived that the program had provided them with more new knowledge and practical information than participants in the pregnancy group. Participants in both groups suggested several opportunities for improving the program.

Conclusions

There were differences between women who dropped out of the intervention during pregnancy and the postpartum follow-up phase. The reported differences between groups should be further examined.

Application and Mechanisms of Internet-Based Cognitive Behavioral Therapy (iCBT) in Improving Psychological State in Cancer Patients

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (iCBT) in Improving Psychological State in Cancer Patients. iCBT's effectiveness has been investigated in treating and managing conditions like depression, psychiatric disorders, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. iCBT's role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. We conducted a thorough literature search using PubMed, Embase, Google Scholar, and Wanfang with no restrictions on the date. iCBT's role in treating and controlling psychiatric illnesses in cancer patients has been established in the literature. Development and popularization of iCBT, treament forms of iCBT, platforms for iCBT, application of iCBT, strategies and efficacy of iCBT for insomnia in cancer patients, current status of iCBT application, and genetic researches on iCBT for anxiety disorders were all reviewed and discussed in this review. From the data compiled, we conclude that iCBT is useful in treating or improving psychological state in cancer patients.

The Appalachia Mind Health Initiative (AMHI): a pragmatic randomized clinical trial of adjunctive internet-based cognitive behavior therapy for treating major depressive disorder among primary care patients

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease morbidity. Combined treatment with antidepressant medication (ADM) plus psychotherapy yields a much higher MDD remission rate than ADM only. But 77% of US MDD patients are nonetheless treated with ADM only despite strong patient preferences for psychotherapy. This mismatch is due at least in part to a combination of cost considerations and limited availability of psychotherapists, although stigma and reluctance of PCPs to refer patients for psychotherapy are also involved. Internet-based cognitive behaviorial therapy (i-CBT) addresses all of these problems.

METHODS

Enrolled patients (n = 3360) will be those who are beginning ADM-only treatment of MDD in primary care facilities throughout West Virginia, one of the poorest and most rural states in the country. Participating treatment providers and study staff at West Virginia University School of Medicine (WVU) will recruit patients and, after obtaining informed consent, administer a baseline self-report questionnaire (SRQ) and then randomize patients to 1 of 3 treatment arms with equal allocation: ADM only, ADM + self-guided i-CBT, and ADM + guided i-CBT. Follow-up SRQs will be administered 2, 4, 8, 13, 16, 26, 39, and 52 weeks after randomization. The trial has two primary objectives: to evaluate aggregate comparative treatment effects across the 3 arms and to estimate heterogeneity of treatment effects (HTE). The primary outcome will be episode remission based on a modified version of the patient-centered Remission from Depression Questionnaire (RDQ). The sample was powered to detect predictors of HTE that would increase the proportional remission rate by 20% by optimally assigning individuals as opposed to randomly assigning them into three treatment groups of equal size. Aggregate comparative treatment effects will be estimated using intent-to-treat analysis methods. Cumulative inverse probability weights will be used to deal with loss to follow-up. A wide range of self-report predictors of MDD heterogeneity of treatment effects based on previous studies will be included in the baseline SRQ. A state-of-the-art ensemble machine learning method will be used to estimate HTE.

DISCUSSION

The study is innovative in using a rich baseline assessment and in having a sample large enough to carry out a well-powered analysis of heterogeneity of treatment effects. We anticipate finding that self-guided and guided i-CBT will both improve outcomes compared to ADM only. We also anticipate finding that the comparative advantages of adding i-CBT to ADM will vary significantly across patients. We hope to develop a stable individualized treatment rule that will allow patients and treatment providers to improve aggregate treatment outcomes by deciding collaboratively when ADM treatment should be augmented with i-CBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04120285 . Registered on October 19, 2019.

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

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

Insights into internet-delivered cognitive behavioural therapy for public safety personnel: Exploration of client experiences during and after treatment

Canadian public safety personnel (PSP) experience high rates of mental health problems and barriers to receiving care. Internet-delivered cognitive behavioural therapy (ICBT) may help reduce barriers to care; however, there is no literature involving qualitative analyses of client feedback to describe PSP experiences with ICBT. Identifying these experiences is important because it can inform future use of ICBT with this group that has unique needs. The current study was designed to explore how clients (N = 82) experienced ICBT that had been tailored to meet their needs; specifically, the study assessed their perceptions of program impacts, what clients found helpful, and client suggestions for improvements. The ICBT course included five core lessons, client stories, and nine initial additional resources, as well as flexible frequencies (optional, once weekly, or twice weekly) and durations (8 to 16 weeks) of therapist support. A qualitative reliability thematic analysis was used to analyze client communications and feedback. Responses to a Treatment Satisfaction Questionnaire administered at eight weeks post-enrollment were available for 57 clients. Client emails with therapists were also examined among all clients, including an additional 25 clients who did not complete the Treatment Satisfaction Questionnaire. Themes identified in the qualitative analyses were related to: reported impacts and hindering events, helpful and challenging course skills and content, helpful aspects of the course, and areas for improvement. Clients who completed the Treatment Satisfaction Questionnaire and those who did not reported beneficial impacts from the program, with the most commonly endorsed themes being skill development and normalizing mental health issues. Hindering events were experienced by both groups and included timeline challenges, technology challenges, and negative effects. Comments from both groups suggested that clients had more success than challenges when practicing the skills. Thought challenging was the skill most frequently identified as helpful. Clients described many aspects of the program as helpful with the most frequently endorsed themes being the course format and content, the flexible nature of the course, access to additional materials and case stories, and therapist assistance. Clients also provided suggestions for improving the course (e.g., case stories, additional resources, timelines audio and videos). Overall, client communications suggest that ICBT is accepted and perceived as beneficial among PSP. These results informed rapid improvements to the ICBT program tailored for PSP and may inform others seeking to provide digital mental health services to PSP.

Neuropsychological and Psychosocial Consequences of the COVID-19 Pandemic

The coronavirus disease designated as COVID-19 reached the level of a pandemic, affecting countries all across the world. Widespread outbreaks of COVID-19 are associated with psychological distress and symptoms of mental disorders. This article is a narrative review of the existing scientific literature on mental health of the society and interventions relevant to the COVID-19 pandemic. A search in the existing databases using the respective keywords has been carried out. It focuses on the consequences of the pandemic with respect to people’s mental health in different clusters of society, including children, health care workers and their relatives, and pregnant women and their families. The unpredictability of the virus pandemic and its high transmission rate is an emergency of psychological problems and certain neuropsychological symptoms, such as fear and abnormal high anxiety, with respect to the spread of the disease, depression, avoidant behaviors, sleep disturbance, irritability, post-traumatic stress disorder (PTSD), pathological anger, and suicide cases.

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

Background: The UK's Improving Access to Psychological Therapies (IAPT) program is a stepped-care model treating individuals with depression and anxiety disorders. Internet-delivered cognitive behavioral therapy (iCBT) is routinely offered to individuals with mild to moderate symptoms, but its applicability to individuals with severe clinical symptoms and requiring a high-intensity intervention is relatively unknown. The current study sought to investigate the potential impacts of using iCBT as a prequel for patients requiring high-intensity treatment (HIT; face-to-face) for depression and anxiety in IAPT. Methods: The study utilized an open study design. One hundred and twenty-four participants who were on a waiting list for high-intensity, face-to-face psychological treatment were offered iCBT. Psychometric data on symptoms of depression, anxiety, and functioning were collected from participants before starting and on finishing iCBT and at the point of service exit. Therapeutic alliance data were collected from patients and clinicians during treatment. Patient pathway data, such as number of treatment sessions and time in treatment, was also collected and incorporated into the analysis. Results: Significant reductions across primary outcome measures of depression and anxiety, as well as improved functioning, were observed from baseline to iCBT treatment exit, and from iCBT exit to service exit. Analysis of the therapeutic alliance data for patients and clinicians illustrated differences in outcome for those who dropped out and those who completed treatment. Discussion: This study illustrates the potential for using iCBT as a prequel to high-intensity therapy for depression and anxiety disorders and is the first of its kind to do so within IAPT stepped care. The results show that iCBT is a valuable option reducing waiting times and enhancing clinical efficiency. The study contributes to the well-established evidence on online psychological treatments worldwide, but further clinical and service development research is necessary to scale these treatments appropriately.

Feasibility and Acceptability of an Interactive Mental Well-Being Intervention for People With Intellectual Disabilities: Pilot Mixed Methods Study

BACKGROUND

The availability of both digital and traditional mental well-being interventions is rising, but these interventions typically do not consider people with intellectual disabilities as potential users.

OBJECTIVE

The study aimed to explore the acceptability and feasibility of a new digital intervention, developed with and for people with intellectual disabilities, to improve their subjective well-being.

METHODS

Using a single-group pre-post design, participants with intellectual disabilities and their caregivers completed the 4-week intervention. Mixed methods questionnaires assessed the acceptability of the intervention, in addition to self-report and proxy-report measures of subjective well-being and behavioral problems.

RESULTS

A total of 12 men with mild to moderate intellectual disabilities enrolled in and completed the study alongside 8 caregivers. Participant acceptability of the intervention was high, and feedback covered multiple aspects of the intervention, including (1) program concept and design, (2) program content, and (3) intervention usage. Self-rated mood barometers indicated mood improvements for 5 participants, deteriorations for 2 participants, and no observed changes for the remaining participants. Statistical analyses yielded no difference from pretest (median=79; range 39-86) to posttest (median=79; range 21-96) for subjective well-being in people with intellectual disabilities (W=10.5; P=.17) and for behavioral problems (W=14; P=.05).

CONCLUSIONS

People with intellectual disabilities and their caregivers are receptive to using digital well-being interventions, and this research shows such interventions to be feasible in routine practice. Given the acceptability of the intervention, its potential efficacy can now be evaluated in people with intellectual disabilities and symptoms of reduced mental well-being.

Exploring the Relationship Between Usage and Outcomes of an Internet-Based Intervention for Individuals With Depressive Symptoms: Secondary Analysis of Data From a Randomized Controlled Trial

Background

Internet interventions can easily generate objective data about program usage. Increasingly, more studies explore the relationship between usage and outcomes, but they often report different metrics of use, and the findings are mixed. Thus, current evaluations fail to demonstrate which metrics should be considered and how these metrics are related to clinically meaningful change.

Objective

This study aimed to explore the relationship between several usage metrics and outcomes of an internet-based intervention for depression.

Methods

This is a secondary analysis of data from a randomized controlled trial that examined the efficacy of an internet-based cognitive behavioral therapy for depression (Space from Depression) in an adult community sample. All participants who enrolled in the intervention, regardless of meeting the inclusion criteria, were included in this study. Space from Depression is a 7-module supported intervention, delivered over a period of 8 weeks. Different usage metrics (ie, time spent, modules and activities completed, and percentage of program completion) were automatically collected by the platform, and composite variables from these (eg, activities per session) were computed. A breakdown of the usage metrics was obtained by weeks. For the analysis, the sample was divided into those who obtained a reliable change (RC)—and those who did not.

Results

Data from 216 users who completed pre- and posttreatment outcomes were included in the analyses. A total of 89 participants obtained an RC, and 127 participants did not obtain an RC. Those in the RC group significantly spent more time, had more log-ins, used more tools, viewed a higher percentage of the program, and got more reviews from their supporter compared with those who did not obtain an RC. Differences between groups in usage were observed from the first week in advance across the different metrics, although they vanished over time. In the RC group, the usage was higher during the first 4 weeks, and then a significant decrease was observed. Our results showed that specific levels of platform usage, 7 hours total time spent, 15 sessions, 30 tools used, and 50% of program completion, were associated with RC.

Conclusions

Overall, the results showed that those individuals who obtained an RC after the intervention had higher levels of exposure to the platform. The usage during the first half of the intervention was higher, and differences between groups were observed from the first week. This study also showed specific usage levels associated with outcomes that could be tested in controlled studies to inform the minimal usage to establish adherence. These results will help to better understand how to use internet-based interventions and what optimal level of engagement can most affect outcomes.

Trial Registration

ISRCTN Registry ISRCTN03704676; http://www.isrctn.com/ISRCTN03704676

International Registered Report Identifier (IRRID)

RR2-10.1186/1471-244X-14-147

Patient experience of supported computerized CBT in an inner-city IAPT service: a qualitative study

Computerized cognitive behavioural therapy (cCBT) has been developed to address economic and clinical issues around limited access to evidence-based therapy. Supported cCBT (variously termed iCBT or eCBT) has been developed to address issues with the effectiveness of, and engagement with, cCBT. There has been no in-depth qualitative exploration of the patient experience of eCBT within the UK, which might aid improving its effectiveness. The aim of this study was to explore patient experience of eCBT in one inner-city National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) service using a semi-structured interview and Thematic Analysis methodology. Ten patients took part. Six main themes were identified: (1) Being Offered eCBT; (2) How eCBT Compares with Self-help; (3) The Patient's State of Mind; (4) The Relationship with the Supporter; (5) Preferring to Talk; (6) eCBT's Value as a Treatment. Participants in this study indicated a preference for face-to-face talking therapy, but were clear that they could form a therapeutic relationship via asynchronous messaging. They reported clinical benefit from the eCBT programme and online relationship, and acknowledged that accessing this immediately was valuable. Issues around the process of selecting patients for eCBT, including with regard to acknowledging or mitigating any negative emotional effects of eCBT, and how to offer and support users with it, are discussed.