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Doukani A, Quartagno M, Sera F, Free C, Kakuma R, Riper H, Kleiboer A, Cerga-Pashoja A, van Schaik A, Botella C, Berger T, Chevreul K, Matynia M, Krieger T, Hazo JB, Draisma S, Titzler I, Topooco N, Mathiasen K, Vernmark K, Urech A, Maj A, Andersson G, Berking M, Baños RM, Araya R. Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial. J Med Internet Res 2024; 26:e47515. [PMID: 38819882 PMCID: PMC11179025 DOI: 10.2196/47515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. OBJECTIVE This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. METHODS We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. RESULTS Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005). CONCLUSIONS To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance. TRIAL REGISTRATION ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-016-1511-1.
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Affiliation(s)
- Asmae Doukani
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matteo Quartagno
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Francesco Sera
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florance, Italy
| | - Caroline Free
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ritsuko Kakuma
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Heleen Riper
- Department of Psychiatry, Amsterdam University Medial Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Annet Kleiboer
- Department Clinical, Neuro, and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Public Health Institute, Amsterdam, Netherlands
| | - Arlinda Cerga-Pashoja
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anneke van Schaik
- Department of Psychiatry, Amsterdam University Medial Centre, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Academic Department for Depressive Disorders, Dutch Mental Health Care, Amsterdam, Netherlands
| | - Cristina Botella
- Department of Basic Psychology, Clinical and Psychobiology, Universitat Jaume I, Castellón de la Plana, Spain
- Centro de Investigación Biomédica en Red Fisiopatología Obesidad y Nutrición, Instituto Carlos III, Madrid, Spain
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Karine Chevreul
- Unité de Recherche Clinique in Health Economics, Assistance Publique-Hôpitaux de Paris, Paris, France
- Health Economics Research Unit, Inserm, University of Paris, Paris, France
| | - Maria Matynia
- Faculty of Psychology, SWPS University, Warsaw, Poland
| | - Tobias Krieger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Jean-Baptiste Hazo
- Unité de Recherche Clinique in Health Economics, Assistance Publique-Hôpitaux de Paris, Paris, France
- Health Economics Research Unit, Inserm, University of Paris, Paris, France
| | - Stasja Draisma
- Department on Aging, Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, Netherlands
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Naira Topooco
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Kim Mathiasen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Centre for Digital Psychiatry, Mental Health Services of Southern Denmark, Odense, Denmark
| | - Kristofer Vernmark
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Antoine Urech
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Neurology, Inselspital Bern, Bern University Hospital, Bern, Switzerland
| | - Anna Maj
- Faculty of Psychology, SWPS University, Warsaw, Poland
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Rosa María Baños
- Centro de Investigación Biomédica en Red Fisiopatología Obesidad y Nutrición, Instituto Carlos III, Madrid, Spain
- Department of Personality, Evaluation and Psychological Treatments, Universidad de Valencia, Valencia, Spain
| | - Ricardo Araya
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
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Kalde J, Atik E, Stricker J, Schückes M, Neudeck P, Pittig A, Pietrowsky R. Enhancing the effectiveness of CBT for patients with unipolar depression by integrating digital interventions into treatment: A pilot randomized controlled trial. Psychother Res 2023:1-16. [PMID: 37922395 DOI: 10.1080/10503307.2023.2277866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2023] Open
Abstract
OBJECTIVE Blended cognitive behavioral therapy (bCBT) combines face-to-face therapy with digital elements, such as digital health apps. This pilot study aimed to explore the effectiveness and safety of a novel bCBT application for treating unipolar depression in adults combined with cognitive behavioral therapy (CBT) compared to CBT alone in routine care. METHODS Patients (N = 82) were randomly assigned to bCBT (n = 42) or CBT (n = 40) over 12 weeks. bCBT consisted of weekly CBT sessions accompanied by the elona therapy depression module (a bCBT application for unipolar depression) for use between sessions. Standard CBT consisted of weekly CBT sessions. Outcomes (6,12 weeks) were analyzed with linear mixed models. RESULTS Improvements in depressive symptoms (BDI-II, PHQ-9) were descriptively larger for the bCBT group. Yet, this difference did not reach statistical significance. bCBT was superior to standard CBT in secondary outcome measures of psychological health (d = .50) and generalized anxiety symptoms (d = -.45). In other secondary outcomes (BAI, PSWQ, GSE, WHOQOL-BREF), improvements were descriptively larger for bCBT compared to CBT. CONCLUSION This pilot study provided preliminary evidence that bCBT might be advantageous in comparison to CBT alone in the treatment of depression, but larger RCTs of the bCBT application are needed.
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Affiliation(s)
- Jan Kalde
- Department of Experimental Psychology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Ece Atik
- Elona Health GmbH, Düsseldorf, Germany
- Translational Psychotherapy, Georg-Elias-Mueller-Institute of Psychology, University of Goettingen, Göttingen, Germany
| | - Johannes Stricker
- Department of Experimental Psychology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | | | - Peter Neudeck
- Elona Health GmbH, Düsseldorf, Germany
- Department of Clinical Psychology, Technical University Chemnitz, Chemnitz, Germany
| | - Andre Pittig
- Translational Psychotherapy, Georg-Elias-Mueller-Institute of Psychology, University of Goettingen, Göttingen, Germany
| | - Reinhard Pietrowsky
- Department of Experimental Psychology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Bielinski LL, Krieger T, Kley MA, Moggi F, Berger T. Blending an internet-based emotion regulation intervention with face-to-face psychotherapy: Findings from a pilot randomized controlled trial. Internet Interv 2023; 33:100650. [PMID: 37575677 PMCID: PMC10413058 DOI: 10.1016/j.invent.2023.100650] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/15/2023] Open
Abstract
Background Transdiagnostic interventions targeting shared mechanisms may improve treatment of mental health disorders. One way of providing such interventions is through blended treatment. This study examined the addition of an internet-based emotion regulation intervention to face-to-face psychotherapy in an outpatient setting. Methods In a pilot randomized controlled trial, 70 patients with a range of diagnoses were assigned to an internet-based program targeting emotion regulation + treatment as usual (face-to-face psychotherapy; TAU) (n = 35) or TAU (n = 35). Assessments occurred at baseline, after six, and after 12 weeks and included measures of symptom severity, emotion regulation, and various intervention feasibility parameters. Results ITT-analyses revealed no significant group-by-time interaction for the primary and almost all secondary outcomes. Descriptively, between-group effect sizes were in favor of the intervention group for almost all outcomes. Sensitivity analysis with patients who completed a minimum of three modules of the internet-based program showed a significant group-by-time interaction for the Difficulties in Emotion Regulation Scale in favor of the intervention group. The internet-based intervention showed good satisfaction ratings, user experience and usability. Findings from therapist measures complemented patient measures. Conclusion Preliminary results show that an internet-based emotion regulation intervention added to psychotherapy may not reduce symptom severity compared to psychotherapy alone. The intervention was rated positively by patients and therapists regarding several parameters, but certain features still need to be improved. An RCT powered to detect small between-group effect-sizes is necessary to consolidate findings.
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Affiliation(s)
- Laura Luisa Bielinski
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Tobias Krieger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Marijke Amanda Kley
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Franz Moggi
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
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Solness CL, Holdefer PJ, Hsu T, Thomas EBK, O'Hara MW. Relationship Factors in Internet-Delivered Psychological Interventions for Veterans Experiencing Postpartum Depression: Qualitative Analysis. JMIR Ment Health 2023; 10:e46061. [PMID: 37581917 PMCID: PMC10466152 DOI: 10.2196/46061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Internet-delivered psychological interventions (IPIs) have been shown to be effective for a variety of psychological concerns, including postpartum depression. Human-supported programs produce better adherence and larger effect sizes than unsupported programs; however, what it is about support that affects outcomes is not well understood. Therapeutic alliance is one possibility that has been found to contribute to outcomes; however, the specific mechanism is not well understood. Participant perspectives and qualitative methodology are nearly absent from the IPI alliance research and may help provide new directions. OBJECTIVE In this study, we aimed to provide participant perspectives on engagement with an IPI for postpartum depression to help inform alliance research, development of new IPIs, and inform resource allocation. METHODS A qualitative methodology was used to explore participant perspectives of veteran women's engagement with the MomMoodBooster program, a human-supported internet-delivered intervention for postpartum depression. Participants were asked 4 open-ended questions with the 3-month postintervention survey, "In what ways did you find the MomMoodBooster most helpful?" "How do you think the MomMoodBooster could have been improved?" "In what ways did you find the personal coach calls to be helpful?" and "How do you think the personal coach calls could have been improved?" RESULTS Data were collected from 184 participants who responded to at least 1 of the open-ended questions. These were analyzed using thematic analysis and a process of reaching a consensus among coders. The results suggest that not only the engagement with the support person is perceived as a significant contributor to participant experiences while using the MomMoodBooster content but also the relationship factors are particularly meaningful. The results provide insights into the specific qualities of the support person that were perceived as most impactful, such as warmth, empathy and genuineness, and feeling normalized and supported. In addition, the results provide insight into the specific change processes that can be targeted through support interactions, such as encouraging self-reflection and self-care and challenging negative thinking. CONCLUSIONS These data emphasize the importance of relationship factors between support persons and an IPI program for postpartum depression. The findings suggest that focusing on specific aspects of the alliance and the therapeutic relationship could yield fruitful directions for the training of support personnel and for future alliance-based research of internet-delivered treatments.
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Affiliation(s)
- Cara L Solness
- Department of Psychiatry, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Paul J Holdefer
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, United States
| | - Ti Hsu
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, United States
| | - Emily B K Thomas
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, United States
| | - Michael W O'Hara
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, United States
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Grodniewicz JP, Hohol M. Waiting for a digital therapist: three challenges on the path to psychotherapy delivered by artificial intelligence. Front Psychiatry 2023; 14:1190084. [PMID: 37324824 PMCID: PMC10267322 DOI: 10.3389/fpsyt.2023.1190084] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Growing demand for broadly accessible mental health care, together with the rapid development of new technologies, trigger discussions about the feasibility of psychotherapeutic interventions based on interactions with Conversational Artificial Intelligence (CAI). Many authors argue that while currently available CAI can be a useful supplement for human-delivered psychotherapy, it is not yet capable of delivering fully fledged psychotherapy on its own. The goal of this paper is to investigate what are the most important obstacles on our way to developing CAI systems capable of delivering psychotherapy in the future. To this end, we formulate and discuss three challenges central to this quest. Firstly, we might not be able to develop effective AI-based psychotherapy unless we deepen our understanding of what makes human-delivered psychotherapy effective. Secondly, assuming that it requires building a therapeutic relationship, it is not clear whether psychotherapy can be delivered by non-human agents. Thirdly, conducting psychotherapy might be a problem too complicated for narrow AI, i.e., AI proficient in dealing with only relatively simple and well-delineated tasks. If this is the case, we should not expect CAI to be capable of delivering fully-fledged psychotherapy until the so-called "general" or "human-like" AI is developed. While we believe that all these challenges can ultimately be overcome, we think that being mindful of them is crucial to ensure well-balanced and steady progress on our path to AI-based psychotherapy.
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Doukani A, Free C, Araya R, Michelson D, Cerga-Pashoja A, Kakuma R. Practitioners' experience of the working alliance in a blended cognitive-behavioural therapy intervention for depression: qualitative study of barriers and facilitators. BJPsych Open 2022; 8:e142. [PMID: 35876079 PMCID: PMC9344874 DOI: 10.1192/bjo.2022.546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Digital technologies have been widely acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance is a key influence on outcomes in conventional psychotherapy, but little is known about therapists' experiences of forming an effective working alliance in blended interventions that involve in-person psychotherapy and a digital programme. AIMS To investigate psychological well-being practitioners' (PWPs') experiences of the working alliance in a trial of blended cognitive-behavioural therapy (b-CBT) for depression. Trial registration ISRCTN12388725. METHOD Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared with face-to-face CBT. Thematic analysis was used to analyse the data. RESULTS Participants reported four facilitating factors when building and maintaining a working alliance in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT and receiving appropriate training and support. Participants also identified four barriers to building and maintaining a working alliance: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to patients' needs and lack of confidence in delivering b-CBT. CONCLUSIONS Our study is the first specifically to investigate practitioners' perceived facilitators and barriers to forming a working alliance in b-CBT for depression. Findings suggest that PWPs' experiences of the working alliance can be improved by: accounting for the time required to deliver b-CBT in service workflows to reduce time pressures; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.
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Affiliation(s)
- Asmae Doukani
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ricardo Araya
- Health Service and Population Research Department, King's College London, UK
| | | | - Arlinda Cerga-Pashoja
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ritsuko Kakuma
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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