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

Quality of the digital gp visits and characteristics of the users: retrospective observational study

OBJECTIVES

This study compares the demographics, diagnoses, re-admission rates, sick leaves, and prescribed medications of patients accessing digital general practitioner (GP) visits with those of patients opting for traditional face-to-face appointments in a primary health care setting.

DESIGN

The study adopted a retrospective analysis of patient record data collected in 2019, comparing visits to a digital primary health center with traditional health center visits.

SETTING

Primary health care.

PARTICIPANTS

The data encompassed patients who utilized the digital clinic and those who visited public health centers for primary health care services.

MAIN OUTCOME MEASURES

The study assessed demographics, health diagnoses, prescribed medications, sick leave recommendations, re-admission rates, and differences in costs between digital clinic and face-to-face visits. Secondary outcomes included a comparative analysis of medication categories, resolution rates for health problems, and potential impacts on health care utilization.

RESULTS

Digital clinic users were typically younger, more educated, and predominantly female compared with health centre users. Digital visits were well-suited for uncomplicated infections, while health centre appointments were associated with a higher prevalence of chronic conditions. Medication patterns differed between the two modalities, with digital clinic users receiving generic over-the-counter drugs and antibiotics, whereas health centre visits commonly involved cardiac and antihypertensive medications. Sick leave recommendations were slightly higher in the digital clinic, but the difference was not significant. Approximately 70% of health problems addressed in the digital clinic were successfully resolved, and the cost of digital visits was about 50,3% of face-to-face appointments.

CONCLUSION

Digital health care services offer a cost-efficient alternative for specific health problems, appealing to younger, educated individuals, when compared to the users of public health center, and may enable improvement of cost-effectiveness combined with acceptable demand management and patient segmentation practices. The results highlight the potential benefits of digital clinics, particularly for uncomplicated cases, while also emphasizing the importance of suitable referral mechanisms for in-person consultations.

The effectiveness of self-guided interventions in adults with depressive symptoms: a systematic review and meta-analysis

BACKGROUND

Despite promising scalability and accessibility, evidence on the efficacy of self-guided interventions for adult depression is inconclusive. This study investigated their effectiveness and acceptability, considering diverse delivery formats and support levels.

METHODS

We systematically searched PubMed, PsycINFO, Embase, and Cochrane Library until 1st January 2024. Included were randomised controlled trials comparing self-guided interventions with a control condition for adult depression. Two independent researchers extracted data. Effect sizes were pooled using random-effects models, with post-intervention depressive severity compared with control conditions as the primary outcome. Study validity was evaluated using Cochrane Risk of Bias 2.0. This study was pre-registered with OSF (https://osf.io/rd43v).

FINDINGS

We identified 92 studies (111 interventions vs. control comparisons) with 16,706 participants (mean age: 18.78-74.41 years). Compared to controls, self-guided interventions were moderately effective at post-assessment (g = 0.53, 95% CI: 0.45-0.61; I2 = 79.17%) and six to twelve months post-randomisation follow-up (g = 0.32, 95% CI: 0.16-0.48; I2 = 79.19%). Trials with initial human screening (g = 0.59) and interventions delivered in computer programs (g = 1.04) had the significantly largest effect sizes. No differences in treatment effects were observed across support levels, therapy types, commercial availability, or the presence of online discussion forums. Self-guided interventions were less acceptable than control conditions (RR = 0.92, p < 0.001). Most studies showed a moderate to high risk of bias (n = 80).

INTERPRETATION

Existing trials on self-guided interventions are at high risk of bias, potentially overestimating treatment effects. Despite lower acceptability compared to controls, self-guided interventions are moderately effective in treating adult depression, regardless of support levels and online discussion features.

FUNDING

None.

Digital empowerment in mental health: A meta-analysis of internet-based interventions for enhancing mental health literacy

Background

Poor mental health literacy (MHL) in the global population significantly contributes to the treatment gap associated with mental disorders. In the digital age, leveraging Internet-based MHL interventions offers scalability and broader accessibility. This meta-analysis aimed to evaluate the effects of Internet-based interventions in improving MHL and mental health.

Method

Up to Feb 2024, seven databases were searched for Internet-based interventions on MHL (knowledge, stigma, help-seeking attitudes and intentions) and mental disorders (general distress, anxiety, and depressive symptoms). The random-effects meta-analyses at post-intervention and long-term follow-up assessments were performed.

Results

Twenty-nine eligible studies involving 11,582 participants were included. Significant positive effects were observed across various domains: knowledge increase (immediate: g = 0.459, 95 %CI: 0.285 to 0.634; follow-up: g = 0.487, 95 %CI: 0.348 to 0.626), immediate stigma reduction (g = -0.332, 95 %CI: -0.479 to -0.186), immediate enhancement of help-seeking attitudes (g = 0.168, 95 %CI: 0.046 to 0.3291) and help-seeking intentions (g = 0.135, 95 %CI: 0.072 to 0.198), as well as immediate mental health improvements (g = -0.074, 95 %CI: -0.115 to -0.033).

Conclusion

Overall, these findings underscore the promising effects of internet-based interventions in improving MHL and mental health, while maintaining these effects over time remains challenging, particularly in reducing stigma and promoting long-term help-seeking behaviors. Addressing methodological limitations, adopting a more interactive approach, and implementing targeted interventions are crucial to maximizing the effectiveness and advancing mental health care worldwide.

Acceptability and feasibility of SUCCEAT, an intervention for parents of adolescents with anorexia nervosa

OBJECTIVE

"Supporting Carers of Children and Adolescents with Eating Disorders in Austria" (SUCCEAT), a skills training for parents, delivered via workshops (WS) or online modules (ONL), has been proven to be effective in terms of parental distress, caregiver skills, and adolescents' outcome. This study examined the adherence to and the acceptability and feasibility of SUCCEAT.

METHOD

One-hundred parents (86% mothers) of adolescents with anorexia nervosa participated in the 8-week training. Parents were assigned to the WS (n = 50) or ONL (n = 50) format using a quasi-randomised design. Adherence, acceptability, and feasibility were assessed using self-report questionnaires.

RESULTS

Adherence to the sessions was high (66%-98%) for both groups. The usage of the material was comparable between the groups. However, in the WS group, participants actively approached the coaches (71.8% vs. 48.9% often/very often) or other parents (63% vs. 4.4% often/very often) more often. Perceived helpfulness was high in both groups, overall satisfaction and practicability were higher in the WS group.

CONCLUSIONS

Good adherence, acceptability, and feasibility were confirmed for both formats of SUCCEAT, with minimal advantages of the WS regarding satisfaction and contact with other parents and coaches. Thus, both formats can be recommended for implementation in clinical routine.

Acceptability of Gynecologic e-Health Modalities by Hispanic/Latina Women of Reproductive Age

Introduction

Electronic health (e-Health) modalities effectively address healthcare access limitations; however, there are limited data on their adoption by Hispanic/Latina women who are disproportionally affected by health disparities.

Methods

We conducted a cross-sectional study by disseminating an anonymous electronic questionnaire via social media to assess the perception of Hispanic/Latina women of reproductive age regarding facilitators and barriers for using e-Health modalities, including telemedicine and mobile apps, to monitor gynecologic health.

Results

The questionnaire was completed by 351 Hispanic/Latina participants with high levels (98.3%) of advanced technological expertise. Current use of a gynecologic mobile app was reported by 63.8%, primarily for menstruation (85.1%) and ovulation (46.3%) tracking. While only 17.6% of participants were offered the option of a gynecologic consultation via telemedicine, the majority (90.5%) would agree to one. Higher education and advanced technological expertise correlated with acceptance of telemedicine for gynecological consults. Being younger (<29 y/o), a student, not having a preferred gynecologist and having a lower income significantly correlated with gynecologic mobile app acceptability.

Conclusions

We showed that e-Health modalities are highly acceptable for Hispanic/Latina women of reproductive age to facilitate gynecological care and documented factors that are significantly associated with e-Health acceptability. These findings are relevant to public health emergencies that cause access to care limitations disproportionally affecting this already underserved population.

Experiences with telemedicine-based follow-up of chronic conditions: the views of patients and health personnel enrolled in a pragmatic randomized controlled trial

BACKGROUND

Telemedicine is often promoted as a possible solution to some of the challenges healthcare systems in many countries face, and an increasing number of studies evaluate the clinical effects. So far, the studies show varying results. Less attention has been paid to systemic factors, such as the context, implementation, and mechanisms of these interventions.

METHODS

This study evaluates the experiences of patients and health personnel enrolled in a pragmatic randomized controlled trial comparing telemedicine-based follow-up of chronic conditions with usual care. Patients in the intervention group received an individual treatment plan together with computer tablets and home telemonitoring devices to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to respond to health related questions reported to a follow-up service. In response to abnormal measurement results, a follow-up service nurse would contact the patient and consider relevant actions. We conducted 49 interviews with patients and 77 interviews with health personnel and managers at the local centers. The interview data were analyzed using thematic analysis and based on recommendations for conducting process evaluation, considering three core aspects within the process of delivering a complex intervention: (1) context, (2) implementation, and (3) mechanisms of impact.

RESULTS

Patients were mainly satisfied with the telemedicine-based service, and experienced increased safety and understanding of their symptoms and illness. Implementation of the service does, however, require dedicated resources over time. Slow adjustment of other healthcare providers may have contributed to the absence of reductions in the use of specialized healthcare and general practitioner (GP) services. An evident advantage of the service is its flexibility, yet this may also challenge cost-efficiency of the intervention.

CONCLUSIONS

The implementation of a telemedicine-based service in primary healthcare is a complex process that is sensitive to contextual factors and that requires time and dedicated resources to ensure successful implementation.

TRIAL REGISTRATION

The trial was registered in www.

CLINICALTRIALS

gov (NCT04142710). Study start: 2019-02-09, Study completion: 2021-06-30, Study type: Interventional, Intervention/treatment: Telemedicine tablet and tools to perform measurements. Informed and documented consent was obtained from all subjects and next of kin participating in the study.

Cost-effectiveness and cost-utility study of a psychoeducational group intervention for people with depression and physical comorbidity in primary care

OBJECTIVE

To evaluate the cost-effectiveness and cost-utility of a psychoeducational group intervention led by primary care (PC) nurses in relation to customary care to prevent the depression and improve quality of life in patients with physical comorbidity.

DESIGN

Economic evaluation based on data from randomized, multicenter clinical trial with blind response variables and a one-year follow-up, carried in the context of the PSICODEP study.

LOCATION

7 PC teams from Catalonia.

PARTICIPANTS

>50 year-old patients with depression and some physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma.

INTERVENTION

12 psychoeducational group sessions, 1 per week, led by 2 PC nurses with prior training.

MEASUREMENTS

Effectiveness: depression-free days (DFD) calculated from the BDI-II and quality-adjusted life years (QALYs) from the Euroqol-5D. Direct costs: PC visits, mental health, emergencies and hospitalizations, drugs. Indirect costs: days of temporary disability (TD). The incremental cost-effectiveness ratios (ICER), cost-effectiveness (ΔCost/ΔDLD) and cost-utility (ΔCost/ΔQALY) were estimated.

RESULTS

The study includes 380 patients (intervention group [IG] = 204; control group [CG] = 176). 81.6% women; mean age 68.4 (SD = 8.8). The IG had a higher mean cost of visits, less of hospitalizations and less TD than the CG. The difference in costs between the IG and the CG was -357.95€ (95% CI: -2026.96 to 1311.06) at one year of follow-up. There was a mean of 11.95 (95% CI: -15.98 to 39.88) more DFD in the IG than in the CG. QALYs were similar (difference -0.01, 95% CI -0.04 to 0.05). The ICERs were 29.95€/DLD and 35,795€/QALY.

CONCLUSIONS

Psychoeducational intervention is associated with an improvement in DFD, as well as a reduction in costs at 12 months, although not significantly. QALYs were very similar between groups.

The effectiveness of E-health interventions promoting physical activity in cancer survivors: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

This systematic review and meta-analysis aimed to identify whether E-health interventions effectively improve physical activity (PA) in cancer survivors.

METHODS

PubMed, Web of Science, and Cochrane Library databases were searched from inception to October 21, 2023. Randomized controlled trials reporting the effect of E-health interventions on PA among cancer survivors were included. Random-effect models were used to calculate standardized mean differences (SMD) and the 95% confidence interval (CI).

RESULTS

In total, 15 trials with 2,291 cancer survivors were included in this meta-analysis. The results showed that E-health interventions improved moderate to vigorous physical activity (MVPA) among cancer survivors (SMD = 0.26, 95% CI 0.08, 0.43, N = 8, p < 0.001, I2 = 37%), as well as moderate physical activity (MPA) (SMD = 0.22, 95% CI 0.05, 0.38, N = 9, p < 0.001, I2 = 28%) and vigorous physical activity (VPA) (SMD = 0.34, 95% CI 0.15, 0.54, N = 6, p < 0.001, I2 = 11%).

CONCLUSION

E-health interventions are effective at promoting PA among cancer survivors. As current research primarily focuses on immediate post-intervention measurements with limited follow-up data, further investigation is required to explore the long-term effects of E-health interventions on PA.

The meaning that people with severe mental illnesses ascribe to e-health in encounters with healthcare professionals - A repeat interview study

This study sought to explore the meaning that people with severe mental illnesses attribute to e-health solutions regarding user involvement and encounters with healthcare professionals. A qualitative design with a social phenomenological approach was applied, and data were collected via repeat interviews. Using a purposive sampling strategy, eight people with severe mental illness were interviewed two times between August 2021 to May 2022, at three different treatment sites in southern Denmark. To be included, participants needed to be 18-65 years of age, diagnosed with severe mental illness (schizophrenia, bipolar disorder, or depression), and using an e-health solution in collaboration with a health professional. The interviews lasted between 20 and 70 min and were audio recorded and then transcribed. The data were analysed with Braun and Clarke's 6-step thematic analysis. Participants experienced the use of an e-health solution as helpful for structuring their everyday lives, and e-health used together with healthcare professionals was considered to have a positive impact on the collaboration. The participants experienced feeling involved and in control when e-health solutions were used, which engaged them in their treatment. Furthermore, the participants found it important to have had some in-person meetings with healthcare professionals to build trust before the e-health solutions could be implemented successfully. E-health solutions used in collaboration with a trusted healthcare professional whom the participants had met in person tended to affect treatment engagement positively.

eHealth interventions for psychiatry in Switzerland and Russia: a comparative study

Introduction

During the past decade, the use of digital technology to promote mental health has increased dramatically. Additionally, the consequences of the COVID-19 pandemic, such as travel restrictions and the disruption of face-to-face interactions, have led to an increase in the use of digital technologies. A wide variety of technologies have been developed, including messaging chatbots, virtual reality technologies, direct-to-consumer apps, and even technologies that are fully integrated into clinical care tools.

Methods

The following qualitative study is based on the opinions of mental health specialists in both countries regarding the use of digital health technologies in psychiatry in Switzerland and Russia in 2019-2020. We investigate the state of adoption of digital technologies in the field of mental health, the meaning of such technologies, and the crucial factors in the use of such technologies in psychiatry.

Results

Health care professionals in both Russia and Switzerland are well aware of these technologies. However, the use of digital technology to promote mental health has taken different paths in these two health care settings.

Factors associated with mental health of young children during the COVID-19 pandemic in the Netherlands

BACKGROUND

The COVID-19 pandemic and accompanying societal measures have impacted children and their families all over the world. Little is known about the factors associated with mental health outcomes in young children (i.e., 1 to 6 years old) during the pandemic. The current study aimed to examine associations with potential risk and protective factors, i.e., direct COVID-19 exposure factors as well as within-family characteristics.

METHODS

Caregivers of children aged 1-6 years old were recruited in the Netherlands to participate in an ongoing longitudinal research project. In the current study, baseline data-collected during the 1st year of the pandemic-are reported. The final sample consisted of 2762 caregivers who answered questionnaires assessing negative and positive dimensions of their children's mental health (i.e., anxiety, depressive symptoms, anger, sleep problems, positive affect, and self-regulation). Furthermore, caregivers provided information regarding: (1) Direct COVID-19 related factors, i.e., parental infection and death of a family member or close friend due to COVID-19, (2) Family related COVID-19 factors, i.e., parental perceived impact of the pandemic and COVID-19 related parent-child emotion regulation strategies (i.e., active, avoidant and information-focused strategies), (3) General caregiver's distress, i.e., parental mental health, parental feelings of rejection towards their child. Regression analyses were used to examine associations with children's mental health.

RESULTS

Direct COVID-19 related factors were not associated with more mental health problems in the children, though parental COVID-19 infections were related with less anger in children. Family related COVID-19 factors and caregiver's distress were related with children's mental health. Higher parental perceived negative impact of the pandemic, lower parental perceived positive impact of the pandemic, more avoidant as well as more active and information-focused parent-child emotion regulation strategies, more caregiver's mental health problems and more parental feelings of rejection towards their child were related with more mental health problems in the child.

CONCLUSION

Direct exposure to COVID-19 was not related with more mental health problems in the child. Family related COVID-19 factors and caregiver's distress appear to play a more important role for young children's mental health. Findings may inform prevention and intervention programs for potential future global crises as well as other stressful events.

Effects of a Self-Guided Transdiagnostic Smartphone App on Patient Empowerment and Mental Health: Randomized Controlled Trial

BACKGROUND

Mental disorders impact both individuals and health systems. Symptoms and syndromes often remain undetected and untreated, resulting in chronification. Besides limited health care resources, within-person barriers such as the lack of trust in professionals, the fear of stigmatization, or the desire to cope with problems without professional help contribute to the treatment gap. Self-guided mental health apps may support treatment seeking by reducing within-person barriers and facilitating mental health literacy. Digital mental health interventions may also improve mental health related self-management skills and contribute to symptom reduction and the improvement of quality of life.

OBJECTIVE

This study aims to investigate the effects of a self-guided transdiagnostic app for mental health on help seeking, reduced stigma, mental health literacy, self-management skills, mental health symptoms, and quality of life using a randomized controlled design.

METHODS

Overall, 1045 participants (recruited via open, blinded, and web-based recruitment) with mild to moderate depression or anxiety-, sleep-, eating-, or somatization-related psychopathology were randomized to receive either access to a self-guided transdiagnostic mental health app (MindDoc) in addition to care as usual or care as usual only. The core features of the app were regular self-monitoring, automated feedback, and psychological courses and exercises. The coprimary outcomes were mental health literacy, mental health-related patient empowerment and self-management skills (MHPSS), attitudes toward help seeking, and actual mental health service use. The secondary outcomes were psychopathological symptom burden and quality of life. Data were collected at baseline and 8 weeks and 6 months after randomization. Treatment effects were investigated using analyses of covariance, including baseline variables as predictors and applying multiple imputation.

RESULTS

We found small but robust between-group effects for MHPSS (Cohen d=0.29), symptoms burden (Cohen d=0.28), and quality of life (Cohen d=0.19) 8 weeks after randomization. The effects on MHPSS were maintained at follow-up. Follow-up assessments also showed robust effects on mental health literacy and preliminary evidence for the improvement of help seeking. Predictors of attrition were lower age and higher personality dysfunction. Among the non-attritors, predictors for deterioration were less outpatient treatment and higher initial symptom severity.

CONCLUSIONS

A self-guided transdiagnostic mental health app can contribute to lasting improvements in patient empowerment. Symptoms of common mental disorders and quality of life improved faster in the intervention group than in the control group. Therefore, such interventions may support individuals with symptoms of 1 or more internalizing disorders, develop health-centered coping skills, prevent chronification, and accelerate symptom improvement. Although the effects for individual users are small and predictors of attrition and deterioration need to be investigated further, the potential public health impact of a self-guided intervention can be large, given its high scalability.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022531; https://drks.de/search/de/trial/DRKS00022531.

Effectiveness of online mindfulness-based interventions for cancer patients: a systematic review and meta-analysis

PURPOSE

Cancer is the second leading cause of mortality worldwide. Cancer negatively affects individuals' quality of life and overall health. Mindfulness-based interventions appear to be promising in the reduction of cancer- and treatment-related symptoms. This review aimed to determine the effectiveness of online mindfulness-based interventions on distress, anxiety, depression, stress, mindfulness, sleep disturbance, quality of life, rumination, fear of cancer recurrence, fatigue and post-traumatic growth among adult cancer patients.

METHODS

A literature search was conducted across five electronic databases. Only randomized controlled trials were eligible. Two reviewers independently screened the studies, extracted data, and performed quality assessment using the Cochrane risk of bias assessment tool. Meta-analyses were conducted using review manager software, and standardized mean difference was used to determine intervention effects. Heterogeneity was examined using the I2 statistics.

RESULTS

Ten studies were included with a total of 962 participants. Analyses revealed that online mindfulness-based interventions was effective in reducing distress (I2 = 98%；standardized mean difference = -2.21，95% confidence interval: -3.84 to 0.57；P = 0.008)， depression (I2 = 45%；standardized mean difference = -0.33，95% confidence interval: -0.64 to -0.03；P = 0.03), stress (I2 = 97%；standardized mean difference = -2.14，95% confidence interval: -4.24 to -0.03；P = 0.05) and sleep disturbance (I2 = 54%；standardized mean difference = -0.30，95% confidence interval: -0.59 to -0.01；P = 0.04), and improving quality of life (I2 = 94%；standardized mean difference = 0.92，95% confidence interval: 0.09-1.76；P = 0.03). The online mindfulness-based interventions had no significant effects on anxiety, mindfulness, rumination, fear of cancer recurrence, fatigue and post-traumatic growth. Subgroup analyses revealed that online mindfulness-based interventions resulted in higher effect sizes for distress when delivered by website than application, significantly higher effect sizes were also found for online mindfulness-based interventions with guidance, but not on treatment or cancer type. For sleep disturbance, and quality of life, no significant differences between subgroups were found.

CONCLUSION

These results provide preliminary support that online mindfulness-based interventions may be feasible and acceptable, which can be used as an adjuvant therapy for the management of cancer-related symptoms among cancer patients.

E-Health intervention for subthreshold depression: Reach and two-year effects of a randomized controlled trial

BACKGROUND

There is evidence for e-Health interventions for full-blown depression. Little is known regarding commonly untreated subthreshold depression in primary care. This randomized controlled multi-centre trial assessed reach and two-year-effects of a proactive e-Health intervention (ActiLife) for patients with subthreshold depression.

METHODS

Primary care and hospital patients were screened for subthreshold depression. Over 6 months, ActiLife participants received three individualized feedback letters and weekly messages promoting self-help strategies against depression, e.g., dealing with unhelpful thoughts or behavioural activation. The primary outcome depressive symptom severity (Patient Health Questionnaire;PHQ-8) and secondary outcomes were assessed 6, 12 and 24 months.

RESULTS

Of those invited, n = 618(49.2 %) agreed to participate. Of them, 456 completed the baseline interview and were randomized to ActiLife (n = 227) or assessment only (n = 226). Generalised estimation equation analyses adjusting for site, setting and baseline depression revealed that depressive symptom severity declined over time, with no significant group differences at 6 (mean difference = 0.47 points; d = 0.12) and 24 months (mean difference = -0.05 points; d = -0.01). Potential adverse effects were observed at 12 months, with higher depressive symptom severity for ActiLife than control participants (mean difference = 1.33 points; d = 0.35). No significant differences in rates of reliable deterioration or reliable improvement of depressive symptoms were observed. ActiLife increased applied self-help strategies at 6 (mean difference = 0.32; d = 0.27) and 24 months (mean difference = 0.22; d = 0.19), but not at 12 months (mean difference = 0.18; d = 0.15).

LIMITATIONS

Self-report measures and lack of information on patients' mental health treatment.

DISCUSSION

ActiLife yielded satisfactory reach and increased the use of self-help strategies. Data were inconclusive in terms of depressive symptom changes.

Economic evaluation of remote patient monitoring and organizational analysis according to patient involvement: a scoping review

BACKGROUND

A literature review concerning the economic evaluation of telemonitoring was requested by the authority in charge of health evaluation in France, in a context of deployment of remote patient monitoring and identification of its financing. Due to the heterogeneity of existing telemonitoring solutions, it was necessary to stratify the evaluation according to patient involvement. Three levels of patient involvement are considered: weak (automated monitoring), medium (monitoring supported by a professional), and strong (active remote participation).

OBJECTIVES

We performed a scoping review to provide a comprehensive overview of different systems of telemonitoring and their reported cost-effectiveness.

METHODS

Following PRISMA-ScR guidelines, a search was performed in four databases: PubMed, MEDLINE, EMBASE, and Cochrane Library between January 1, 2013 and May 19, 2020. Remote patient monitoring should include the combination of three elements: a connected device, an organizational solution for data analysis and alert management, and a system allowing personalized interactions, and three degrees of involvement.

RESULTS

We identified 61 eligible studies among the 489 records identified. Heart failure remains the pathology most represented in the studies selected (n = 24). The cost-utility analysis was chosen in a preponderant way (n = 41). Forty-four studies (72 percent) reported that the intervention was expected cost-effective. Heterogeneity has been observed in the remote monitoring solutions but all systems are reported cost-effective. The small number of long-term studies does not allow conclusions to be drawn on the transposability.

CONCLUSIONS

Remote patient monitoring is reported to be cost-effective whatever the system and patient involvement.

The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis

BACKGROUND

The benefits of peer support interventions (PSIs) for individuals with mental illness are not well known. The aim of this systematic review and meta-analysis was to assess the effectiveness of PSIs for individuals with mental illness for clinical, personal, and functional recovery outcomes.

METHODS

Searches were conducted in PubMed, Embase, and PsycINFO (December 18, 2020). Included were randomized controlled trials (RCTs) comparing peer-delivered PSIs to control conditions. The quality of records was assessed using the Cochrane Collaboration Risk of Bias tool. Data were pooled for each outcome, using random-effects models.

RESULTS

After screening 3455 records, 30 RCTs were included in the systematic review and 28 were meta-analyzed (4152 individuals). Compared to control conditions, peer support was associated with small but significant post-test effect sizes for clinical recovery, g = 0.19, 95% CI (0.11-0.27), I2 = 10%, 95% CI (0-44), and personal recovery, g = 0.15, 95% CI (0.04-0.27), I2 = 43%, 95% CI (1-67), but not for functional recovery, g = 0.08, 95% CI (-0.02 to 0.18), I2 = 36%, 95% CI (0-61). Our findings should be considered with caution due to the modest quality of the included studies.

CONCLUSIONS

PSIs may be effective for the clinical and personal recovery of mental illness. Effects are modest, though consistent, suggesting potential efficacy for PSI across a wide range of mental disorders and intervention types.

Effectiveness of the SAFE eHealth Intervention for Women Experiencing Intimate Partner Violence and Abuse: Randomized Controlled Trial, Quantitative Process Evaluation, and Open Feasibility Study

BACKGROUND

Intimate partner violence and abuse (IPVA) is a pervasive societal issue that impacts many women globally. Web-based help options are becoming increasingly available and have the ability to eliminate certain barriers in help seeking for IPVA, especially in improving accessibility.

OBJECTIVE

This study focused on the quantitative evaluation of the SAFE eHealth intervention for women IPVA survivors.

METHODS

A total of 198 women who experienced IPVA participated in a randomized controlled trial and quantitative process evaluation. Participants were largely recruited on the internet and signed up through self-referral. They were allocated (blinded for the participants) to (1) the intervention group (N=99) with access to a complete version of a help website containing 4 modules on IPVA, support options, mental health, and social support, and with interactive components such as a chat, or (2) the limited-intervention control group (N=99). Data were gathered about self-efficacy, depression, anxiety, and multiple feasibility aspects. The primary outcome was self-efficacy at 6 months. The process evaluation focused on themes, such as ease of use and feeling helped. In an open feasibility study (OFS; N=170), we assessed demand, implementation, and practicality. All data for this study were collected through web-based self-report questionnaires and automatically registered web-based data such as page visits and amount of logins.

RESULTS

We found no significant difference over time between groups for self-efficacy, depression, anxiety, fear of partner, awareness, and perceived support. However, both study arms showed significantly decreased scores for anxiety and fear of partner. Most participants in both groups were satisfied, but the intervention group showed significantly higher scores for suitability and feeling helped. However, we encountered high attrition for the follow-up surveys. Furthermore, the intervention was positively evaluated on multiple feasibility aspects. The average amount of logins did not significantly differ between the study arms, but participants in the intervention arm did spend significantly more time on the website. An increase in registrations during the OFS (N=170) was identified: the mean amount of registrations per month was 13.2 during the randomized controlled trial and 56.7 during the OFS.

CONCLUSIONS

Our findings did not show a significant difference in outcomes between the extensive SAFE intervention and the limited-intervention control group. It is, however, difficult to quantify the real contribution of the interactive components, as the control group also had access to a limited version of the intervention for ethical reasons. Both groups were satisfied with the intervention they received, with the intervention study arm significantly more so than the control study arm. Integrated and multilayered approaches are needed to aptly quantify the impact of web-based IPVA interventions for survivors.

TRIAL REGISTRATION

Netherlands Trial Register NL7108 NTR7313; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7313.

Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Depression is common and associated with substantial burden. Suicide rates have increased over the past decade, and both suicide attempts and deaths have devastating effects on individuals and families.

Objective

To review the benefits and harms of screening and treatment for depression and suicide risk and the accuracy of instruments to detect these conditions among primary care patients.

Data Sources

MEDLINE, PsychINFO, Cochrane library through September 7, 2022; references of existing reviews; ongoing surveillance for relevant literature through November 25, 2022.

Study Selection

English-language studies of screening or treatment compared with control conditions, or test accuracy of screening instruments (for depression, instruments were selected a priori; for suicide risk, all were included). Existing systematic reviews were used for treatment and test accuracy for depression.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Findings were synthesized qualitatively, including reporting of meta-analysis results from existing systematic reviews; meta-analyses were conducted on original research when evidence was sufficient.

Main Outcomes and Measures

Depression outcomes; suicidal ideation, attempts, and deaths; sensitivity and specificity of screening tools.

Results

For depression, 105 studies were included: 32 original studies (N=385 607) and 73 systematic reviews (including ≈2138 studies [N ≈ 9.8 million]). Depression screening interventions, many of which included additional components beyond screening, were associated with a lower prevalence of depression or clinically important depressive symptomatology after 6 to 12 months (pooled odds ratio, 0.60 [95% CI, 0.50-0.73]; reported in 8 randomized clinical trials [n=10 244]; I2 = 0%). Several instruments demonstrated adequate test accuracy (eg, for the 9-item Patient Health Questionnaire at a cutoff of 10 or greater, the pooled sensitivity was 0.85 [95% CI, 0.79-0.89] and specificity was 0.85 [95% CI, 0.82-0.88]; reported in 47 studies [n = 11 234]). A large body of evidence supported benefits of psychological and pharmacologic treatment of depression. A pooled estimate from trials used for US Food and Drug Administration approval suggested a very small increase in the absolute risk of a suicide attempt with second-generation antidepressants (odds ratio, 1.53 [95% CI, 1.09-2.15]; n = 40 857; 0.7% of antidepressant users had a suicide attempt vs 0.3% of placebo users; median follow-up, 8 weeks). Twenty-seven studies (n = 24 826) addressed suicide risk. One randomized clinical trial (n=443) of a suicide risk screening intervention found no difference in suicidal ideation after 2 weeks between primary care patients who were and were not screened for suicide risk. Three studies of suicide risk test accuracy were included; none included replication of any instrument. The included suicide prevention studies generally did not demonstrate an improvement over usual care, which typically included specialty mental health treatment.

Conclusions and Relevance

Evidence supported depression screening in primary care settings, including during pregnancy and postpartum. There are numerous important gaps in the evidence for suicide risk screening in primary care settings.

oVRcome - Self-guided virtual reality for specific phobias: A randomised controlled trial

OBJECTIVE

Mobile health applications for mental health are widely accessible but most have had limited research evaluation. Virtual reality exposure therapy is an emerging treatment for specific phobias. Most virtual reality studies have investigated high-end virtual reality devices, typically only available in research and limited clinical settings for a single phobia. This study evaluated the effectiveness of oVRcome, a mobile health application combining self-guided virtual reality exposure and cognitive behaviour therapy, for five specific phobias.

METHODS

This is a 2-arm 6-week randomised controlled trial, with a waitlist control group and follow-up at week 12. Participants were required to live in New Zealand; be aged 18-64 years; have a fear of flying, heights, spiders, dogs and needles; score above 4 on the Brief Standard Self-rating scale for phobic patients; and have access to a smartphone and Internet. oVRcome consists of six modules of psychoeducation, relaxation, mindfulness, cognitive techniques, exposure through virtual reality and relapse prevention over 6 weeks. The primary outcome was the change from baseline to week 6 on the Severity Measures for Specific Phobia - Adults. All analyses were performed on intention-to-treat set.

RESULTS

A total of 126 participants were randomised, and 109 completed the follow-up at week 6, for a retention rate of 86.5%. The mean change in Severity Measures for Specific Phobia - Adults score from baseline to week 6 was greater in the active group compared with the waitlist group (active group -20.53 [standard deviation = 8.24]; waitlist group: - 12.31 [standard deviation = 10.66]; p < 0.001). The effect size for this difference was 0.86.

CONCLUSION

Self-guided use of the oVRcome app was effective at reducing severity of specific phobia symptoms in a sample of people with a self-reported fear of flying, heights, spiders, dogs or needles.Trial registry clinicaltrials.gov NCT04909177.

Working alliance in low-intensity internet-based cognitive behavioral therapy for depression in primary care in Spain: A qualitative study

Introduction

Psychotherapies delivered via the Internet have been promoted as an alternative for improving access to psychological treatments. A conceptual working alliance model of blended (i.e., traditional face-to-face consultation combined with Internet-delivered psychotherapy) cognitive-behavioral therapy (b-CBT) for depression has been developed in the UK. However, little is known about how this important therapeutic process, namely the working alliance (WA), is developed and maintained in Internet-delivered cognitive-behavioral therapy without face-to-face consultation (i-CBT). The aim of this study was to evaluate the validity of the WA model of b-CBT in Spanish patients with depression receiving i-CBT.

Methods

Forty-one patients suffering from mild-moderate depression were interviewed to assess their experiences of an i-CBT program. Interviews were conducted with participants who received a self-guided application (n = 9), and low-intensity support (n = 10). Three group interviews were also conducted with patients who either did not start the program (n = 8) or did not complete it (n = 6), and with patients who did complete it (n = 8).

Results

Qualitative thematic content analysis was performed using the constant comparative method, which revealed four main themes: "bond," "goals," "task," and "usability heuristics," all consistent with the existing literature. However, a new subcategory emerged, called "anonymity," which may highlight the social stigma that mental illness still has in the Spanish context.

Conclusion

Results suggest that the development and maintenance of the WA through i-CBT could offer a better experience of the therapeutic process and improve the clinical impact.

Clinical Trial Registration

Clinicaltrials.gov, identifier: NCT01611818.

Enhancing Internet-based psychotherapy for adults with emotional disorders using ecological momentary assessments and interventions: Study protocol of a feasibility trial with "My EMI, Emotional Well-being" app

Introduction

Emotional disorders are the most frequent mental health problems globally. To ensure the dissemination of psychological treatments for these conditions, novel forms of delivery (e.g., Internet or mobile apps) and more scalable forms of psychotherapy (e.g., transdiagnostic interventions) have become increasingly popular. Research, however, shows that a significant number of patients, around 40 % according to some studies, do not respond to the interventions as expected (i.e., not-on-track patients). Ecological momentary assessments (EMAs) and ecological momentary interventions (EMIs) could simplify tailoring treatments to the patients' progress and rapidly respond to undesired outcomes during psychotherapy. Therefore, these would facilitate measurement-based care with little therapist involvement. This study aims to explore the feasibility of an app-based system called My EMI, Emotional Well-being for people with emotional disorders. According to daily EMAs, the app will provide personalized EMIs while participants receive a self-applied online transdiagnostic treatment. The app will be used as an add-tool to the online intervention to address emotion dysregulation, foster adherence, and reinforce contents. The current study describes the study protocol for this trial.

Method and analysis

A single-group, open trial design will be used. Participants will be 30 adults suffering from emotional disorders. Primary outcomes will be app usability, acceptability, and response rates. Secondary outcomes will be either evaluated in Qualtrics at pre-treatment, post-treatment, and 3-month follow-up (depression and anxiety severity, and transdiagnostic dimensions of emotional disorders) or daily throughout the study with the app (EMAs of mood and five transdiagnostic mechanisms of therapeutic change). EMIs will consist of brief, evidence-based transdiagnostic CBT digital content (images, infographics, or videos) delivered just-in-time. Only if problems persist, short phone calls or episodic videocalls will be conducted. The Ethics Committee of the Jaume I University approved the study and all its procedures (CD/111/2021) in December 2021.

Discussion

Identifying personalized and scalable interventions is paramount to improve mental health care, especially its accessibility, and to reduce the psychological distress of people with mental health problems. Feasibility data of the app (EMA and EMI system) supported by a self-applied online transdiagnostic intervention will be important to explore whether this modern approach is a real option to move forward personalized psychological interventions for persons with emotional disorders.

Trial registration

ClinicalTrials.gov Identifier: NCT05109780. Registered 05 November 2021, https://clinicaltrials.gov/ct2/show/NCT05109780.

Forensic Psychiatric Outpatients' and Therapists' Perspectives on a Wearable Biocueing App (Sense-IT) as an Addition to Aggression Regulation Therapy: Qualitative Focus Group and Interview Study

BACKGROUND

Given the increased use of smart devices and the advantages of individual behavioral monitoring and assessment over time, wearable sensor-based mobile health apps are expected to become an important part of future (forensic) mental health care. For successful implementation in clinical practice, consideration of barriers and facilitators is of utmost importance.

OBJECTIVE

The aim of this study was to provide insight into the perspectives of both psychiatric outpatients and therapists in a forensic setting on the use and implementation of the Sense-IT biocueing app in aggression regulation therapy.

METHODS

A combination of qualitative methods was used. First, we assessed the perspectives of forensic outpatients on the use of the Sense-IT biocueing app using semistructured interviews. Next, 2 focus groups with forensic therapists were conducted to gain a more in-depth understanding of their perspectives on facilitators of and barriers to implementation.

RESULTS

Forensic outpatients (n=21) and therapists (n=15) showed a primarily positive attitude toward the addition of the biocueing intervention to therapy, with increased interoceptive and emotional awareness as the most frequently mentioned advantage in both groups. In the semistructured interviews, patients mainly reported barriers related to technical or innovation problems (ie, connection and notification issues, perceived inaccuracy of the feedback, and limitations in the ability to personalize settings). In the focus groups with therapists, 92 facilitator and barrier codes were identified and categorized into technical or innovation level (n=13, 14%), individual therapist level (n=28, 30%), individual patient level (n=33, 36%), and environmental and organizational level (n=18, 20%). The predominant barriers were limitations in usability of the app, patients' motivation, and both therapists' and patients' knowledge and skills. Integration into treatment, expertise within the therapists' team, and provision of time and materials were identified as facilitators.

CONCLUSIONS

The chances of successful implementation and continued use of sensor-based mobile health interventions such as the Sense-IT biocueing app can be increased by considering the barriers and facilitators from patients' and therapists' perspectives. Technical or innovation-related barriers such as usability issues should be addressed first. At the therapist level, increasing integration into daily routines and enhancing affinity with the intervention are highly recommended for successful implementation. Future research is expected to be focused on further development and personalization of biocueing interventions considering what works for whom at what time in line with the trend toward personalizing treatment interventions in mental health care.

Costs and Cost-Effectiveness of mCME Version 2.0: An SMS-Based Continuing Medical Education Program for HIV Clinicians in Vietnam

This cost analysis found that a mobile phone-based continuing medical education (mCME) intervention, involving daily text messages with links to relevant materials, for HIV clinicians in northern Vietnam was relatively low-cost and cost-effective, particularly for future nationwide models. Such mobile approaches to CME are worthy of attention in resource-constrained settings.

Background:

The Mobile Continuing Medical Education (mCME) 2.0 project was a randomized controlled trial that found that a 6-month text message-based CME intervention improved both the use of online medical training resources and medical knowledge among a cadre of HIV clinicians in Vietnam. This companion study analyzed intervention costs and cost-effectiveness.

Methods:

We conducted (1) a financial analysis based on costs incurred during the trial’s planning and implementation; (2) an economic analysis to consider resource utilization; and (3) cost-effectiveness analyses to estimate cost inputs relative to impact: increase in self-study (measured by visits to online courses) and increase in knowledge (measured by exam score improvement) (in 2016 US$). Finally, we estimated the economic cost of a 9-month national program and a 10-year scaled-up model (in 2021 US$).

Results:

The total financial cost of the intervention was US$49,552; the main cost drivers were personnel time (71.4%) and technology inputs (14.9%). The total economic cost was estimated at US$92,212, with the same key cost inputs (representing 77.7% and 8.0%, respectively, of total costs). The financial cost per 10% increase in accessing online courses was US$923, while the cost of improving knowledge, measured by a 10% improvement in mean exam score across the study population, was US$32,057 (US$605 per intervention clinician). The comparable total economic cost of each improvement, respectively, was US$1,770 and US$61,452 (US$1,159 per intervention clinician). A future 9-month national program was estimated to cost US$37,403, while the full 10-year scaled-up program was estimated at US$196,446.

Conclusions:

This analysis indicates that leveraging mobile technology could be a feasible way to provide distance learning to health professions across Vietnam at a relatively low cost. Given the need for practical ways to expand CME in resource-constrained regions of the world, this approach warrants further study and possible adoption.

Mental Health of People Under Isolation During the covid-19 Outbreak: An Exploratory Study

We conducted an exploratory study using a survey inquiring on seven topics on how people were reacting to the covid-19 pandemic of 2020 aiming to trace a map of symptoms and feelings related to mental health and isolation. 1785 people participated in the survey. Additionally, we applied two psychological scales to analyze depression and stress (prevalent in previous studies). We found that people in isolation during the pandemic presented symptoms related to dissociative disorders, negative affect, and anxiety syndrome. Also, depression and stress had a high prevalence compared to the average rates indicated by the World Health Organisation and the Colombian Ministry of Health. The results indicated an association between depression and stress and being previously diagnosed with a mental health problem, and job and financial situation. Our results highlight the need to design prevention and intervention programmes to reduce the negative consequences of isolation.

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

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

The Feasibility of Providing Remote Functional Family Therapy with Adolescents During the COVID-19 Pandemic: A Mixed-Method Study

Background

Due to the recent COVID-19 pandemic, mental health care has largely transferred its services to online platforms, using videoconferencing (VC) or teletherapy. Within the field of family therapy, however, there is little evidence on the feasibility of using VC, especially when working with whole families at the edge of care.

Objective

This study investigated the feasibility of remote Functional Family Therapy (FFT), using a mixed-method approach.

Method

Study 1 consisted of semi-structured interviews with 23 FFT professionals (18 female) about their experience of providing remote FFT during the COVID-19 pandemic. Study 2 included monitoring data of 209 FFT clients (46% female, M age  = 14.00) who participated in FFT during the pandemic. We compared families who received mainly in-person, mainly remote or a mix of remote and in-person on client-reported alliance, drop-out, therapist-rated outcomes, and treatment intensity using MANCOVA's and chi-square tests.

Results

In Study 1 two themes emerged around experienced challenges, namely 'Feeling in control' and 'Engagement and alliance'. Two other themes emerged around adaptations, namely 'Being more on top' and 'Connecting in different ways'. In Study 2, we found that the therapeutic alliance was not related to using VC. Also, families had less between-session contact during the Engagement and Motivation Phase when receiving mainly VC, but had more sessions and longer therapy when receiving a mix of in-person and remote therapy.

Conclusions

The current study suggests that providing systemic family teletherapy to families on the edge of care is feasible. Further development of systemic family teletherapy is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10566-022-09692-y.

Cost Effectiveness of Digital Interventions for Generalised Anxiety Disorder: A Model-Based Analysis

BACKGROUND

Digital interventions (DIs) are increasingly being used in mental health care, despite limited evidence regarding their value for money. This study aimed to evaluate the cost effectiveness of DIs for generalised anxiety disorder (GAD), in comparison with alternative care options, from the perspective of the UK health care system.

METHODS

An open-source decision analytic cohort model was used to extrapolate the results of a network meta-analysis over a patient's lifetime and estimate the costs and outcomes (quality-adjusted life-years) of DIs and their comparators. The net monetary benefit (NMB) and probability of cost effectiveness was estimated for each comparator, and we conducted a Value of Information analysis to evaluate the scale and drivers of uncertainty.

RESULTS

DIs were associated with lower NMB compared with medication and with group therapy, but greater NMB compared with non-therapeutic controls and with usual care. DIs that were supported by a clinician, an assistant or a lay person had higher delivery costs than purely patient-self-directed DIs, yielding a greater NMB when opportunity cost was above £3000/QALY. There was considerable uncertainty in the findings driven largely by uncertainty in the estimated treatment effects. The value of further research to establish the effectiveness of DIs for GAD was substantial, at least £12.9 billion.

CONCLUSIONS

The high uncertainty about these results does not allow for recommendations based on the cost effectiveness of DIs. However, the analysis highlights areas for future research, and demonstrates that apparent cost savings associated with DIs can be offset by reduced effectiveness.

The experience of participating in an internet-based cognitive behavioral therapy program among patients with cardiovascular disease and depression: a qualitative interview study

BACKGROUND

Depression in conjunction with cardiovascular disease (CVD) is associated with worsening in CVD, higher mortality, and poorer quality of life. Despite the poor outcomes there is a treatment gap of depression in CVD patients. Recently we found that an Internet-based cognitive behavioral therapy (iCBT) tailored for CVD patients led to reduced symptoms of depression. However, we still have little knowledge about CVD patients' experiences of working with iCBT. The aim of this study was therefore to explore CVD patients' experiences of engaging in a tailored iCBT program.

METHODS

A qualitative interview study using inductive thematic analysis. Data was obtained from 20 patients with CVD and depressive symptoms who had participated in a randomized controlled trial (RCT) evaluating the impact of a nine-week iCBT program on depression.

RESULTS

Three main themes emerged: (1) Taking control of the disease, (2) Not just a walk in the park, and (3) Feeling a personal engagement with the iCBT program. The first theme included comments that the tailored program gave the patients a feeling of being active in the treatment process and helped them achieve changes in thoughts and behaviors necessary to take control of their CVD. The second theme showed that patients also experienced the program as demanding and emotionally challenging. However, it was viewed as helpful to challenge negative thinking about living with CVD and to change depressive thoughts. In the third theme patients reported that the structure inherent in the program, in the form of organizing their own health and the scheduled feedback from the therapist created a feeling of being seen as an individual. The feeling of being acknowledged as a person also made it easier to continuously work with the changes necessary to improve their health.

CONCLUSIONS

Engaging in an iCBT program tailored for patients with CVD and depression was by the patients perceived as helpful in the treatment of depression. They experienced positive changes in emotions, thoughts, and behaviors which a result of learning to take control of their CVD, being confirmed and getting support. The patients considered working with the iCBT program as demanding and emotionally challenging, but necessary to achieve changes in emotions, thoughts, and behaviors.

Cost-effectiveness of Web-Based and Home-Based Postnatal Psychoeducational Interventions for First-time Mothers: Economic Evaluation Alongside Randomized Controlled Trial

BACKGROUND

The cost-effectiveness of interventions has attracted increasing interest among researchers. Although web-based and home-based psychoeducational interventions have been developed to improve first-time mothers' postnatal health outcomes, very limited studies have reported their cost-effectiveness.

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of web-based and home-based postnatal psychoeducational interventions for first-time mothers during the early postpartum period.

METHODS

A randomized controlled 3-group pretest and posttest design was adopted, and cost-effectiveness analysis from the health care's perspective was conducted. A total of 204 primiparas were recruited from a public tertiary hospital in Singapore from October 2016 to August 2017 who were randomly allocated to the web-based intervention (n=68), home-based intervention (n=68), or control (n=68) groups. Outcomes of maternal parental self-efficacy, social support, postnatal depression, anxiety, and health care resource utilization were measured using valid and reliable instruments at baseline and at 1 month, 3 months, and 6 months after childbirth. The generalized linear regression models on effectiveness and cost were used to assess the incremental cost-effectiveness ratios of the web-based and home-based intervention programs compared to routine care. Projections of cumulative cost over 5 years incurred by the 3 programs at various coverage levels (ie, 10%, 50%, and 100%) were also estimated.

RESULTS

The web-based intervention program dominated the other 2 programs (home-based program and routine care) with the least cost (adjusted costs of SGD 376.50, SGD 457.60, and SGD 417.90 for web-based, home-based, and control group, respectively; SGD 1=USD 0.75) and the best improvements in self-efficacy, social support, and psychological well-being. When considering the implementation of study programs over the next 5 years by multiplying the average cost per first-time mother by the estimated average number of first-time mothers in Singapore during the 5-year projection period, the web-based program was the least costly program at all 3 coverage levels. Based on the 100% coverage, the reduced total cost reached nearly SGD 7.1 million and SGD 11.3 million when compared to control and home-based programs at the end of the fifth year, respectively.

CONCLUSIONS

The web-based approach was promisingly cost-effective to deliver the postnatal psychoeducational intervention to first-time mothers and could be adopted by hospitals as postnatal care support.

TRIAL REGISTRATION

ISRCTN registry ISRCTN45202278; https://www.isrctn.com/ISRCTN45202278.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

ClinicalTrial.gov : NCT04958941 Registered 7 Jun 2021.

STUDY STATUS

Participant recruitment has not started.

iHealth: The ethics of artificial intelligence and big data in mental healthcare

The concept of intelligent health (iHealth) in mental healthcare integrates artificial intelligence (AI) and Big Data analytics. This article is an attempt to outline ethical aspects linked to iHealth by focussing on three crucial elements that have been defined in the literature: self-monitoring, ecological momentary assessment (EMA), and data mining. The material for the analysis was obtained by a database search. Studies and reviews providing outcome data for each of the three elements were analyzed. An ethical framing of the results was conducted that shows the chances and challenges of iHealth. The synergy between self-monitoring, EMA, and data mining might enable the prevention of mental illness, the prediction of its onset, the personalization of treatment, and the participation of patients in the treatment process. Challenges arise when it comes to the autonomy of users, privacy and data security of users, and potential bias.

Promoting Mental Health in Parents of Young Children Using eHealth Interventions: A Systematic Review and Meta-analysis

Parent stress and mental health problems negatively impact early child development. This study aimed to systematically review and meta-analyze the effect of eHealth interventions on parent stress and mental health outcomes, and identify family- and program-level factors that may moderate treatment effects. A search of PsycINFO, Medline, CINAHL, Cochrane and Embase databases was conducted from their inception dates to July 2020. English-language controlled and open trials were included if they reported: (a) administration of an eHealth intervention, and (b) stress or mental health outcomes such as self-report or clinical diagnosis of anxiety and depression, among (c) parents of children who were aged 1–5 years old. Non-human studies, case reports, reviews, editorials, letters, dissertations, and books were excluded. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Random-effects meta-analyses of standardized mean differences (SMD) were conducted and meta-regressions tested potential moderators. 38 studies were included (N = 4360 parents), from 13 countries (47.4% USA). Meta-analyses indicated eHealth interventions were associated with better self-reported mental health among parents (overall SMD = .368, 95% CI 0.228, 0.509), regardless of study design (k = 30 controlled, k = 8 pre-post) and across most outcomes (k = 17 anxiety, k = 19 depression, k = 12 parenting stress), with small to medium effect sizes. No significant family- or program-level moderators emerged. Despite different types and targets, eHealth interventions offer a promising and accessible option to promote mental health among parents of young children. Further research is needed on moderators and the long-term outcomes of eHealth interventions. Prospero Registration: CRD42020190719.

Development and Evaluation of the Usefulness, Usability, and Feasibility of iNNOV Breast Cancer: Mixed Methods Study

BACKGROUND

Despite the efficacy of psychosocial interventions in minimizing psychosocial morbidity in breast cancer survivors (BCSs), intervention delivery across survivorship is limited by physical, organizational, and attitudinal barriers, which contribute to a mental health care treatment gap in cancer settings.

OBJECTIVE

The aim of this study is to develop iNNOV Breast Cancer (iNNOVBC), a guided, internet-delivered, individually tailored, acceptance and commitment therapy-influenced cognitive behavioral intervention program aiming to treat mild to moderate anxiety and depression in BCSs as well as to improve fatigue, insomnia, sexual dysfunction, and health-related quality of life in this group. This study also aims to evaluate the usefulness, usability, and preliminary feasibility of iNNOVBC.

METHODS

iNNOVBC was developed using a user-centered design approach involving its primary and secondary end users, that is, BCSs (11/24, 46%) and mental health professionals (13/24, 54%). We used mixed methods, namely in-depth semistructured interviews, laboratory-based usability tests, short-term field trials, and surveys, to assess iNNOVBC's usefulness, usability, and preliminary feasibility among these target users. Descriptive statistics were used to characterize the study sample, evaluate performance data, and assess survey responses. Qualitative data were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Overall, participants considered iNNOVBC highly useful, with most participants reporting on the pertinence of its scope, the digital format, the relevant content, and the appropriate features. However, various usability issues were identified, and participants suggested that the program should be refined by simplifying navigation paths, using a more dynamic color scheme, including more icons and images, displaying information in different formats and versions, and developing smartphone and tablet versions. In addition, participants suggested that tables should be converted into plain textboxes and data visualization dashboards should be included to facilitate the tracking of progress. The possibility of using iNNOVBC in a flexible manner, tailoring it according to BCSs' changing needs and along the cancer care continuum, was another suggestion that was identified.

CONCLUSIONS

The study results suggest that iNNOVBC is considered useful by both BCSs and mental health professionals, configuring a promising point-of-need solution to bridge the psychological supportive care gap experienced by BCSs across the survivorship trajectory. We believe that our results may be applicable to other similar programs. However, to fulfill their full supportive role, such programs should be comprehensive, highly usable, and tailorable and must adopt a flexible yet integrated structure capable of evolving in accordance with survivors' changing needs and the cancer continuum.

Digital interventions in mental health: evidence syntheses and economic modelling

BACKGROUND

Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives.

OBJECTIVES

(1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions.

METHODS

We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders.

RESULTS

In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'.

LIMITATIONS

There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias.

CONCLUSIONS

Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'.

FUTURE WORK

There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105837.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 1. See the NIHR Journals Library website for further project information.

An Evaluation of 5-Year Web Analytics for HeadsUpGuys: A Men's Depression E-Mental Health Resource

The present study reports an evaluation of web analytics, over a 5-year period, for HeadsUpGuys.org, an eHealth resource for men with depression. Google Analytics, Search Console, and Tag Manager were used to monitor user activity over the course of the website's first 5 years (June 15, 2015-June 15, 2020). Through this period, HeadsUpGuys had a total of 1,665,356 unique users, amounting to 1,948,481 sessions and 3,328,258 page views. Organic traffic accounted for the highest proportion (53.44%; n = 1,041,277) of website sessions. Four of the top 10 Google search queries that brought users to the website related to suicidality. Three countries (United States, United Kingdom, Canada) accounted for almost three-quarters (71.10%; n = 1,385,485) of the site's traffic. Nearly three-quarters (73.35%; n = 1,429,285) of sessions occurred on a mobile device. The goal conversion rate for the Self Check was 60.27%. The average time on page was 2 min 53 s, with a bounce rate of 65.92%, and an exit rate of 57.20%. The goal conversion rate for the Stress Test was 52.89%. The average time on page was 4 min 8 s, with a bounce rate of 72.40% and an exit rate of 48.88%. The conversion rate for the final goal was 11.53%, indicating that approximately one in 10 visitors to the site had a session of at least 3 min. The findings illustrate the potential of eHealth resources to support men's mental health and provide a real-world benchmark to help advance the men's eHealth field.

Prevalence and related factors of depression and anxiety in a cohort of Chinese elderly caregivers in the nursing home

BACKGROUND

The heavy care burden, the long-term dependence of the disabled elderly, and the changing social roles can put elderly caregivers at high risk for mental disorders. This study aimed to explore the prevalence and related factors of depression and anxiety among elderly caregivers and examine the role of resilience in depression and anxiety.

METHODS

A multicentre cross-sectional survey was designed. A total of 953 elderly caregivers in nursing homes were recruited in three provinces in China using convenience sampling. Depression and anxiety were measured by self-rating depression scale (SDS) and self-rating anxiety scale (SAS). Multivariate logistic regression analysis was used to explore the key factors associated with depression and anxiety.

RESULTS

The median SDS score was 40 (interquartile interval 34-48), and the median SAS score was 48 (interquartile interval 38-56). In this cohort, 19.4% reported depression and 44.0% anxiety. Working hours, sensitive personality and health status were related factors for depression symptom. In terms of anxiety symptoms, its related factors included working hours, health status and higher monthly income. Furthermore, resilience was associated with depression and anxiety among caregivers.

LIMITATIONS

A selection bias may be caused by convenience sampling and voluntary participation.

CONCLUSION

Depression and anxiety symptoms were common in the cohort of Chinese elderly caregivers in the nursing home. The factors explored in this study may contribute to the development of individualized interventions for depression and anxiety symptoms.

Effectiveness of Telehealth Interventions for Women With Postpartum Depression: Systematic Review and Meta-analysis

BACKGROUND

Postpartum depression (PPD) is a prevalent mental health problem with serious adverse consequences for affected women and their infants. Clinical trials have found that telehealth interventions for women with PPD result in increased accessibility and improved treatment effectiveness. However, no comprehensive synthesis of evidence from clinical trials by systematic review has been conducted.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of telehealth interventions in reducing depressive symptoms and anxiety in women with PPD. To enhance the homogeneity and interpretability of the findings, this systematic review focuses on PPD measured by the Edinburgh Postnatal Depression Scale (EPDS).

METHODS

PubMed, The Cochrane Library, CINAHL, PsycINFO, CNKI, and Wanfang were electronically searched to identify randomized controlled trials (RCTs) on the effectiveness of telehealth interventions for women with PPD from inception to February 28, 2021. Data extraction and quality assessment were performed independently by two researchers. The quality of included studies was assessed using the Cochrane risk-of-bias tool, and meta-analysis was performed using RevMan 5.4 software.

RESULTS

Following the search, 9 RCTs with a total of 1958 women with PPD were included. The EPDS (mean difference=-2.99, 95% CI -4.52 to -1.46; P<.001) and anxiety (standardized mean difference=-0.39, 95% CI -0.67 to -0.12; P=.005) scores were significantly lower in the telehealth group compared with the control group. Significant subgroup differences were found in depressive symptoms according to the severity of PPD, telehealth technology, specific therapy, and follow-up time (P<.001).

CONCLUSIONS

Telehealth interventions could effectively reduce the symptoms of depression and anxiety in women with PPD. However, better designed and more rigorous large-scale RCTs targeting specific therapies are needed to further explore the potential of telehealth interventions for PPD.

TRIAL REGISTRATION

PROSPERO CRD42021258541; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258541.

Use of Telemedicine in Depression Care by Physicians: Scoping Review

BACKGROUND

Depression is a common disorder, and it creates burdens on people's mental and physical health as well as societal costs. Although traditional in-person consultations are the usual mode of caring for patients with depression, telemedicine may be well suited to psychiatric assessment and management. Telepsychiatry can be defined as the use of information and communication technologies such as videoconferencing and telephone calls for the care of psychopathologies.

OBJECTIVE

This review aims to evaluate the extent and nature of the existing literature on the use of telemedicine for the care of depression by physicians. This review also aims to examine the effects and perceptions regarding this virtual care and determine how it compares to traditional in-person care.

METHODS

The Arksey and O'Malley framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines were followed. Relevant articles were identified through a search of three databases (MEDLINE, Cochrane Database of Systematic Reviews, and PsycArticles) on October 11, 2020. The search terms were "(virtual OR telemedicine OR teleconsultation* OR telehealth OR phone* OR webcam* OR telepsychiatry) AND (depress*)". Eligibility criteria were applied to select studies about the use of telemedicine for the care of patients with depression specifically by physicians. An Excel file (Microsoft Corporation) was used to chart data from all included articles.

RESULTS

The search resulted in the identification of 28 articles, and all 13 nonreview studies were analyzed in detail. Most nonreview studies were conducted in the United States during the last decade. Most telemedicine programs were led by psychiatrists, and the average study population size was 135. In all applicable studies, telepsychiatry tended to perform at least as well as in-person care regarding improvement in depression severity, patient satisfaction, quality of life, functioning, cost-effectiveness, and most other perceptions and variables. Cultural sensitivity and collaborative care were part of the design of some telemedicine programs.

CONCLUSIONS

Additional randomized, high-quality studies are recommended to evaluate various outcomes of the use of telemedicine for depression care, including depression variables, perceptions, health care outcomes and other outcomes. Studies should be conducted in various clinical contexts, including primary care. Telepsychiatry is a promising modality of care for patients suffering from depression.

New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing.

OBJECTIVE

This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects.

METHODS

We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model.

RESULTS

The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs.

CONCLUSIONS

Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.

Health-economic evaluation of psychological interventions for depression prevention: Systematic review

Psychological interventions have been proven to be effective to prevent depression, however, little is known on the cost-effectiveness of psychological interventions for the prevention of depression in various populations. A systematic review was conducted using PubMed, PsycINFO, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Econlit, NHS Economic Evaluations Database, NHS Health Technology Assessment and OpenGrey up to January 2021. Only health-economic evaluations based on randomized controlled trials of psychological interventions to prevent depression were included. Independent evaluators selected studies, extracted data and assessed the quality using the Consensus on Health Economic Criteria and the Cochrane Risk of Bias Tool. Twelve trial-based economic evaluations including 5929 participants from six different countries met the inclusion criteria. Overall, the quality of most economic evaluations was considered good, but some studies have some risk of bias. Setting the willingness-to-pay upper limit to US$40,000 (2018 prices) for gaining one quality adjusted life year (QALY), eight psychological preventive interventions were likely to be cost-effective compared to care as usual. The likelihood of preventive psychological interventions being more cost-effective than care as usual looks promising, but more economic evaluations are needed to bridge the many gaps that remain in the evidence-base. ETHICS: As this systematic review is based on published data, approval from the local ethics committee was not required.

A mixed methods exploration of "Creativity in Mind", an online creativity-based intervention for low mood and anxiety

BACKGROUND

Within the current context of a global pandemic, the value of the Internet has been greatly elevated for many people. This study is an investigation into a 30-day online intervention called Creativity in Mind (CIM).

AIMS

To provide a preliminary indication of the relationship between participation in CIM and change in mood symptoms and wellbeing.

METHODS

A co-produced mixed methods design was used to evaluate CIM. Data was obtained from 55 participants. Each day for 30 days participants received a predetermined creative challenge that they were encouraged to complete and share within the group. Measures of mood and wellbeing were collected at three time points, including a 3-month follow-up. Qualitative interviews were undertaken with 18 participants and analysed using framework analysis.

RESULTS

Scores on mood and wellbeing measures showed an overall significant improvement following completion of the programme. However, only a small number of participants demonstrated clinically significant improvement (14%) or deterioration (5%). The qualitative data indicated that CIM was experienced positively, with some negative emotions arising from the volume of interactions and negative comparisons made between participants.

CONCLUSIONS

Preliminary results demonstrate that the pattern of clinically significant change across individual participants was comparable to other psychological therapy.

Mental health specialist video consultations versus treatment as usual in patients with depression or anxiety disorders in primary care: study protocol for an individually randomised superiority trial (the PROVIDE-C trial)

BACKGROUND

Most people with mental disorders, including those with severe and chronic disorders, are treated solely by their general practitioner (GP). Nevertheless, specialised mental health care may be required for specific patients. Notably, the accessibility of mental health specialist care is mainly complicated by (a) long waiting times for an appointment with specialists, (b) long travel distances to specialists, particularly in rural and remote areas, and (c) patients' reservations about mental health specialist care (including fear of being stigmatised by seeking such care). To mitigate those barriers, technology-based integrated care models have been proposed. The purpose of this study is to examine the effectiveness and cost-effectiveness of a mental health specialist video consultations model versus treatment as usual in patients with depression or anxiety disorders in primary care.

METHODS

In an individually randomised, prospective, two-arm superiority trial with parallel group design, N = 320 patients with anxiety and/or depressive disorder will be recruited in general practices in Germany. The intervention includes a newly developed treatment model based on video consultations with focus on diagnostics, treatment planning, and short-term intervention by mental health specialists. We will systematically compare the effectiveness, cost-effectiveness, and adverse effects of this new model with usual care by the GP: the primary outcome is the absolute change in the mean depressive and anxiety symptom severity measured on the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) from baseline to 6 months after baseline assessment. Follow-up in both groups will be conducted by blinded outcome assessors at 6 months and 12 months after baseline. The main analysis will be based on the intention-to-treat principle. We will optimise the likelihood of treatment effectiveness by strict inclusion criteria for patients, enhanced intervention integrity, and conducting a process evaluation.

DISCUSSION

To the best of our knowledge, this is the first confirmatory study on a video-based, integrated care model for the treatment of anxiety and depressive disorders in GP patients in Germany.

TRIAL REGISTRATION

ClinicalTrials.gov, United States National Institutes of Health NCT04316572 . Prospectively registered on 20 March 2020.

Feasibility of mHealth interventions for depressive symptoms in Latin America: a systematic review

Depression is a prevalent disorder and leading cause of disability in Latin America, where the mental health treatment gap is still above 50%. We sought to synthesise and assess the quality of the evidence on the feasibility of mHealth-based interventions for depression in Latin America. We conducted a literature search of studies published in 2007 and after using four electronic databases. We included peer-reviewed articles, in English, Spanish or Portuguese, that evaluated interventions for depressive symptoms. Two authors independently extracted data using forms developed a priori. We assessed appropriateness of reporting utilising the CONSORT checklist for feasibility trials. Eight manuscripts were included for full data extraction. Appropriate reporting varied greatly. Most (n = 6, 75%) of studies were conducted in primary care settings and sought to deliver psychoeducation or behaviour change interventions for depressive symptoms. We found great heterogeneity in the assessment of feasibility. Two studies used comparator conditions. mHealth research for depression in Latin America is scarce. Included studies showed some feasibility despite methodological inconsistencies. Given the dire need for evidence-based mental health interventions in this region, governments and stakeholders must continue promoting and funding research tailored to cultural and population characteristics with subsequent pragmatic clinical trials.

A Direct-to-Public Peer Support Program (Big White Wall) Versus Web-Based Information to Aid the Self-management of Depression and Anxiety: Results and Challenges of an Automated Randomized Controlled Trial

Background

Effective help for depression and anxiety reaches a small proportion of people who might benefit from it. The scale of the problem suggests the need for effective, safe web-based public health services delivered directly to the public. One model, the Big White Wall (BWW), offers peer support at low cost. As these interventions are delivered digitally, we tested whether a randomized controlled trial (RCT) intervention could also be fully delivered and evaluated digitally.

Objective

This study aims to determine the reach, feasibility, acceptability, baseline costs, and outcomes of a public health campaign for an automated RCT of the BWW, providing digital peer support and information, compared with a standard website used by the National Health Service Moodzone (MZ), to people with probable mild-to-moderate depression and anxiety disorder. The primary outcome was the change in self-rated well-being at 6 weeks, measured using the Warwick-Edinburgh Mental Well-Being Scale.

Methods

An 18-month campaign was conducted across Nottinghamshire, the United Kingdom (target population 914,000) to advertise the trial directly to the public through general marketing, web-based and social media sources, health services, other public services, and third-sector groups. The population reach of this campaign was examined by the number of people accessing the study website and self-registering to the study. A pragmatic, parallel-group, single-blind RCT was then conducted using a fully automated trial website in which eligible participants were randomized to receive either 6 months of access to BWW or signposted to MZ. Those eligible for participation were aged >16 years with probable mild-to-moderate depression or anxiety disorders.

Results

Of 6483 visitors to the study website, 1510 (23.29%) were eligible. Overall, 790 of 1510 (52.32%) visitors participated. Of 790 visitors, 397 (50.3%) were randomized to BWW and 393 (49.7%) to MZ. Their mean age was 38 (SD 13.8) years, 81.0% (640/790) were female, 93.4% (738/790) were White, and 47.4% (271/572) had no contact with health services in the previous 3 months. We estimated 3-month productivity losses of £1001.01 (95% CI 868.75-1133.27; US $1380.79; 95% CI 1198.35-1563.23) per person for those employed. Only 16.6% (131/790) participants completed the primary outcome assessment. There were no differences in the primary or secondary outcomes between the 2 groups.

Conclusions

Most participants reached and those eligible for this trial of digital interventions were White women not in recent contact with health services and whose productivity losses represent a significant annual societal burden. A fully automated RCT recruiting directly from the public failed to recruit and retain sufficient participants to test the clinical effectiveness of this digital intervention, primarily because it did not personally engage participants and explain how these unfamiliar interventions might benefit them.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 12673428; https://www.isrctn.com/ISRCTN12673428

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8061

A Mobile App for Self-management of Urgency and Mixed Urinary Incontinence in Women: Randomized Controlled Trial

BACKGROUND

Many women experience urgency (UUI) and mixed (MUI) urinary incontinence but commonly hesitate to seek care. Treatment access and self-management for these conditions can be supported through eHealth approaches.

OBJECTIVE

This study aimed to investigate the efficacy of the mobile app Tät II for self-management of UUI and MUI in women.

METHODS

This randomized controlled trial included women ≥18 years old with UUI or MUI and ≥2 leakages per week. Those with red-flag symptoms were excluded. Participants were recruited via analog and digital advertisements and screened for initial selection through a web-based questionnaire. Data were collected using another questionnaire and a 2-day bladder diary. A telephone interview confirmed the symptom diagnosis. Participants were randomized (1:1) to receive access to a treatment app (including pelvic floor muscle training, bladder training, psychoeducation, lifestyle advice, tailored advice, exercise log, reinforcement messages, and reminders) or an information app (control group), with no external treatment guidance provided. The primary outcome was incontinence symptoms at the 15-week follow-up, measured using the International Consultation on Incontinence Questionnaire (ICIQ)-Urinary Incontinence Short Form (ICIQ-UI SF). Urgency symptoms were assessed using the ICIQ-Overactive Bladder Module (ICIQ-OAB) and quality of life using the ICIQ-Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSqol). Incontinence episode frequency (IEF) was calculated per bladder diary entries. Improvement was measured using the Patient's Global Impression of Improvement. All outcomes were self-reported. Cure was defined as no leakages per the bladder diary. Intention-to-treat analysis was performed.

RESULTS

Between April 2017 and March 2018, 123 women (mean age 58.3, SD 9.6 years) were randomized to the treatment (n=60, 2 lost to follow-up) or information (n=63) group. Of these, 35 (28%) women had UUI, and 88 (72%) had MUI. Mean ICIQ-UI SF score at follow-up was lower in the treatment group than in the information group (estimated difference -3.1, 95% CI -4.8 to -1.3). The estimated between-group difference was -1.8 (95% CI -2.8 to -0.99) for mean ICIQ-OAB score and -6.3 (95% CI -10.5 to -2.1) for the mean ICIQ-LUTSqol score at follow-up. IEF reduction from baseline to follow-up was greater in the treatment group (-10.5, IQR -17.5 to -3.5) than in the information group (P<.001). Improvement was reported by 87% (52/60) of treatment group participants and by 30% (19/63) of information group participants. The cure rate was 32% in the treatment group, and 6% in the information group (odds ratio 5.4, 95% CI 1.9-15.6; P=.002). About 67% (40/60) of the treatment group participants used the app more than thrice a week.

CONCLUSIONS

The treatment app was effective for improving urgency and mixed incontinence in women. When self-management is appropriate, this app may be a good alternative to pharmacological treatment or other conservative management, thus increasing access to care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03097549; https://clinicaltrials.gov/ct2/show/NCT03097549.

E-mental health applications for depression: an evidence-based ethical analysis

E-mental health applications (apps) are an increasingly important factor for the treatment of depression. To assess the risks and benefits for patients, an in-depth ethical analysis is necessary. The objective of this paper is to determine the ethical implications of app-based treatment for depression. An evidence-based ethical analysis was conducted. The material was meta-reviews and randomized control studies (RCTs) on app-based treatment. Based on the empirical data, an ethical analysis was conducted using the 3-ACES-approach by Thornicroft and Tansella. Apps may empower autonomy, offer an uninterrupted series of contacts over a period of time, show evidence-based benefits for patients with subclinical and mild-to-moderate-symptoms, are easily accessible, may be used for coordinating information and services within an episode of care, and are on the whole cost-effective. Their risks are that they are not suitable for the whole range of severity of mental illnesses and patient characteristics, show severe deficits in the data privacy policy, and a big variability in quality standards. The use of apps in depression treatment can be beneficial for patients as long as (1) the usefulness of an app-based treatment is assessed for each individual patient, (2) apps are chosen according to symptom severity as well as characteristics like the patient's level of self-reliance, their e-literacy, and their openness vis-à-vis apps, (3) manufacturers improve their privacy policies and the quality of apps.

Evidence Synthesis of Digital Interventions to Mitigate the Negative Impact of the COVID-19 Pandemic on Public Mental Health: Rapid Meta-review

Background

Accumulating evidence suggests the COVID-19 pandemic has negative effects on public mental health. Digital interventions that have been developed and evaluated in recent years may be used to mitigate the negative consequences of the pandemic. However, evidence-based recommendations on the use of existing telemedicine and internet-based (eHealth) and app-based mobile health (mHealth) interventions are lacking.

Objective

The aim of this study was to investigate the theoretical and empirical base, user perspective, safety, effectiveness, and cost-effectiveness of digital interventions related to public mental health provision (ie, mental health promotion, prevention, and treatment of mental disorders) that may help to reduce the consequences of the COVID-19 pandemic.

Methods

A rapid meta-review was conducted. The MEDLINE, PsycINFO, and CENTRAL databases were searched on May 11, 2020. Study inclusion criteria were broad and considered systematic reviews and meta-analyses that investigated digital tools for health promotion, prevention, or treatment of mental health conditions and determinants likely affected by the COVID-19 pandemic.

Results

Overall, 815 peer-reviewed systematic reviews and meta-analyses were identified, of which 83 met the inclusion criteria. Our findings suggest that there is good evidence on the usability, safety, acceptance/satisfaction, and effectiveness of eHealth interventions. Evidence on mHealth apps is promising, especially if social components (eg, blended care) and strategies to promote adherence are incorporated. Although most digital interventions focus on the prevention or treatment of mental disorders, there is some evidence on mental health promotion. However, evidence on process quality, cost-effectiveness, and long-term effects is very limited.

Conclusions

There is evidence that digital interventions are particularly suited to mitigating psychosocial consequences at the population level. In times of physical distancing, quarantine, and restrictions on social contacts, decision makers should develop digital strategies for continued mental health care and invest time and efforts in the development and implementation of mental health promotion and prevention programs.

Workforce challenges in digital health implementation: How are clinical psychology training programmes developing digital competences?

Objectives

Digital practice in psychological services is a rapidly expanding and innovative area which is supporting continuation of clinical provision during the COVID-19 pandemic. Training the workforce to deliver safe and effective online psychological provision is key to service success and relies on accurate mapping of competences and current training needs. This paper discusses the initial stage for developing the first digital mental health competence framework for applied psychology in the UK. It reports on the digital training currently provided nationally and barriers/facilitators to acquiring these competencies.

Methods

Eighteen of the thirty UK Clinical Psychology Doctoral training programmes completed a 16-item survey. This mapped current digital health teaching and skills acquisition for trainee Clinical Psychologists throughout their 3-year pre-registration training. Furthermore, potential barriers and facilitators to developing these digital skills for both trainee and qualified Clinical Psychologists were investigated.

Results

The quantitative analysis highlighted the majority of respondents viewed developing digital mental health competencies with importance, but were not integrating this into teaching or clinical placements activity. The qualitative, inductive content analysis revealed seven key themes influencing the development of digital mental health skills, with the majority of respondents identifying with two themes; the need for practice guidelines (50% of respondents) and opportunities for digital mental health experience.

Conclusions

The findings suggest the need for a greater focus on developing the digital health knowledge, skills, and confidence across trainee and qualified Clinical Psychologists. Strategic analysis indicated the need to develop a framework for digital mental health competences across the curriculum and placement experience. Easily accessible learning packages may support the implementation of training nationally.

Predictors of Adherence in Three Low-Intensity Intervention Programs Applied by ICTs for Depression in Primary Care

Depression is one of the most common disorders in psychiatric and primary care settings, and is associated with disability, loss in quality of life, and economic costs. Internet-based psychological interventions have been shown to be effective in depression treatment but present problems with a low degree of adherence. The main aim of this study is to analyze the adherence predictors in three low-intensity interventions programs applied by Information and Communication Technologies (ICTs) for depression. A multi-center, randomized, controlled clinical trial was conducted with 164 participants with depression, who were allocated to: Healthy Lifestyle Program, Positive Affect Promotion Program or Mindfulness Program. Sociodemographic characteristics, Patient Health Questionnaire-9, Visual Analog Scale, Short Form Health Survey, Positive and Negative Affect Schedule, Five Facets Mindfulness Questionnaire, Pemberton Happiness Index and Treatment Expectancy Questionnaire were used to study adherence. Results showed that positive affect resulted in a predictor variable for Healthy Lifestyle Program and Positive Affect Promotion Program. Perceived health was also a negative adherence predictor for the Positive Affect Promotion Program. Our findings demonstrate that there are differences in clinical variables between treatment completers and non-completers and we provide adherence predictors in two intervention groups. Although new additional predictors have been examined, further research is essential in order to improve tailored interventions and increase adherence treatment.