Harnessing Peer Support in an Online Intervention for Older Adults with Depression

Persuasive design principle of social support in digital interventions targeting mental health symptoms: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis evaluates the available evidence on efficacy of social support strategies, as defined by the persuasive system design framework, in internet-based and mobile-based interventions (IMI) targeting mental health.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing IMI implementing a social support strategy for mental health symptoms to various control conditions. Publications up to June 2023 (date of search 6 June 2023) were considered.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened and extracted data in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed with the Risk of Bias Tool V.2.0. Data were pooled based on a random-effects model.

RESULTS

After screening 6484 records, a total of 45 studies met our inclusion criteria. At 96%, social support was predominantly implemented through the strategy of social facilitation, by which users recognising others using the intervention (eg, discussion forum). IMI implementing social support strategies showed moderate effect sizes of Hedges' g=-0.34 (95% CI -0.47 to -0.21, p<0.001) in comparison to different control conditions. Heterogeneity was considerable (I2=73.6%; 95% CI 64.8 to 80.3). Subgroup analyses revealed a significant influence of targeted psychological condition (p<0.001), type of social support (p<0.001) and control condition (p<0.001). In k=11 component studies (ie, comparison to a disentangled version of the same intervention), IMI with social support strategies were not significantly more effective in comparison to the same IMI without social support (Hedges' g=-0.08 (95% CI -0.22 to 0.05, p=0.19, I2=0%). 64% (k=7) of component studies reported higher adherence rates in IMI with social support.

CONCLUSIONS

Based on a small number of component studies, implementing social support strategies in IMI that target mental health symptoms has no significant incremental benefit on effectiveness. To draw more robust conclusions, the potential of other social support strategies besides social facilitation should be exploited in future component studies.

PROSPERO REGISTRATION NUMBER

CRD42020222810.

Uptake and engagement of a clinically moderated digital peer support platform to support the mental well-being older adults: a qualitative investigation

BACKGROUND

The uptake of traditional mental health services among older adults remains low. Digital peer support offers older adults a resource for engaging with others to independently support their mental well-being. This qualitative study explored the uptake and engagement of a clinically moderated digital peer support platform (Breathing Space) for older adults with depressive symptoms and alcohol use concerns.

METHODS

Semi-structured interviews with 30 participants aged 60-80 years explored participants' uptake and engagement with Breathing Space, a novel, moderated, private, and anonymous peer support platform. Data were analysed using reflective thematic analysis and are discussed with reference to the Unified Theory of Acceptance and Use of Technology2.

RESULTS

Three themes were constructed to characterize participants' experiences: (i) navigating the complexities of peer-peer online engagement; (ii) the function of anonymity in online connection; and (iii) experiences of app features and content.

CONCLUSIONS

Future development of digital peer support for older adults would benefit from the following: (i) co-design with older adults; (ii) providing choice over anonymity and increased options for interacting with peers; (iii) streamlining the basic functionality with popular platforms; (iv) providing options for users to curate their digital experience; and (v) providing telephone support for troubleshooting technical difficulties. Future research should explore the use of digital peer support among older adults who experience social exclusion challenges.

Acceptability of Digital Mental Health Interventions for Depression and Anxiety: Systematic Review

BACKGROUND

Depression and anxiety disorders are common, and treatment often includes psychological interventions. Digital health interventions, delivered through technologies such as web-based programs and mobile apps, are increasingly used in mental health treatment. Acceptability, the extent to which an intervention is viewed positively, has been identified as contributing to patient adherence and engagement with digital health interventions. Acceptability, therefore, impacts the benefit derived from using digital health interventions in treatment. Understanding the acceptability of digital mental health interventions among patients with depression or anxiety disorders is essential to maximize the effectiveness of their treatment.

OBJECTIVE

This review investigated the acceptability of technology-based interventions among patients with depression or anxiety disorders.

METHODS

A systematic review was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PROSPERO (International Prospective Register of Systematic Reviews) guidelines. We searched PubMed, Web of Science, and Ovid in May 2022. Studies were included if they evaluated digital interventions for the treatment of depression or anxiety disorders and investigated their acceptability among adult patients. Studies were excluded if they targeted only specific populations (eg, those with specific physical health conditions), investigated acceptability in healthy individuals or patients under the age of 18 years, involved no direct interaction between patients and technologies, used technology only as a platform for traditional care (eg, videoconferencing), had patients using technologies only in clinical or laboratory settings, or involved virtual reality technologies. Acceptability outcome data were narratively synthesized by the direction of acceptability using vote counting. Included studies were evaluated using levels of evidence from the Oxford Centre for Evidence-Based Medicine. The risk of bias was assessed using a tool designed for this review and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation).

RESULTS

A total of 143 articles met the inclusion criteria, comprising 67 (47%) articles on interventions for depression, 65 (45%) articles on interventions for anxiety disorders, and 11 (8%) articles on interventions for both. Overall, 90 (63%) were randomized controlled trials, 50 (35%) were other quantitative studies, and 3 (2%) were qualitative studies. Interventions used web-based programs, mobile apps, and computer programs. Cognitive behavioral therapy was the basis of 71% (102/143) of the interventions. Digital mental health interventions were generally acceptable among patients with depression or anxiety disorders, with 88% (126/143) indicating positive acceptability, 8% (11/143) mixed results, and 4% (6/143) insufficient information to categorize the direction of acceptability. The available research evidence was of moderate quality.

CONCLUSIONS

Digital mental health interventions seem to be acceptable to patients with depression or anxiety disorders. Consistent use of validated measures for acceptability would enhance the quality of evidence. Careful design of acceptability as an evaluation outcome can further improve the quality of evidence and reduce the risk of bias.

TRIAL REGISTRATION

Open Science Framework Y7MJ4; https://doi.org/10.17605/OSF.IO/SPR8M.

Role of Synchronous, Moderated, and Anonymous Peer Support Chats on Reducing Momentary Loneliness in Older Adults: Retrospective Observational Study

BACKGROUND

Older adults have a high rate of loneliness, which contributes to increased psychosocial risk, medical morbidity, and mortality. Digital emotional support interventions provide a convenient and rapid avenue for additional support. Digital peer support interventions for emotional struggles contrast the usual provider-based clinical care models because they offer more accessible, direct support for empowerment, highlighting the users' autonomy, competence, and relatedness.

OBJECTIVE

This study aims to examine a novel anonymous and synchronous peer-to-peer digital chat service facilitated by trained human moderators. The experience of a cohort of 699 adults aged ≥65 years was analyzed to determine (1) if participation, alone, led to measurable aggregate change in momentary loneliness and optimism and (2) the impact of peers on momentary loneliness and optimism.

METHODS

Participants were each prompted with a single question: "What's your struggle?" Using a proprietary artificial intelligence model, the free-text response automatched the respondent based on their self-expressed emotional struggle to peers and a chat moderator. Exchanged messages were analyzed to quantitatively measure the change in momentary loneliness and optimism using a third-party, public, natural language processing model (GPT-4 [OpenAI]). The sentiment change analysis was initially performed at the individual level and then averaged across all users with similar emotion types to produce a statistically significant (P<.05) collective trend per emotion. To evaluate the peer impact on momentary loneliness and optimism, we performed propensity matching to align the moderator+single user and moderator+small group chat cohorts and then compare the emotion trends between the matched cohorts.

RESULTS

Loneliness and optimism trends significantly improved after 8 (P=.02) to 9 minutes (P=.03) into the chat. We observed a significant improvement in the momentary loneliness and optimism trends between the moderator+small group compared to the moderator+single user chat cohort after 19 (P=.049) and 21 minutes (P=.04) for optimism and loneliness, respectively.

CONCLUSIONS

Chat-based peer support may be a viable intervention to help address momentary loneliness in older adults and present an alternative to traditional care. The promising results support the need for further study to expand the evidence for such cost-effective options.

Evaluating the Experience of Teen-to-Teen Crisis Line Volunteers: A Pilot Study

Teen-to-teen (t2t) crisis lines are a special type of crisis service where youth volunteers help their peers. Although prior research has examined the experience of adult crisis line responders, no research has examined the experience of adolescents who do this work. In collaboration with two of the largest t2t lines in the U.S., this pilot study is the first examination of t2t crisis line work. Volunteers (ages 14-20) reported: their primary motivation for joining the crisis lines was to help others and give back to the community; responding to a range of peers' problems on the t2t crisis line, including high-risk suicide contacts; and a range of ways the crisis line work impacted their lives. Findings provide preliminary information about the experience of adolescents engaging in t2t crisis line work. Additional research is needed in larger and more diverse samples to understand the impact of crisis line work for youth.

Effectiveness of digital intelligence interventions on depression and anxiety in older adults: A systematic review and meta-analysis

BACKGROUND

Depression and anxiety are common mental disorders in later life. Digital intelligence interventions overcome the limitations of conventional psychotherapy and offer new treatments for depression and anxiety. However, the effectiveness among older adults remains unclear.

METHODS

Databases including Pubmed, Web of Science, the Cochrane Library, Medline, CINAHL, PsycINFO, and Embase were searched for Randomized Controlled Trials (RCTs) from inception to November 22, 2023. Statistical analyses were conducted using Stata 18.0 and Review Manager 5.4.

RESULTS

The initial search found 9369 papers, with 21 meeting the inclusion criteria (e.g., RCTs involving older adults aged 50 and older that assessed digital intelligence interventions on depression and anxiety symptoms). Meta-analyses revealed that, compared to control groups, digital intelligence interventions significantly reduced depression symptoms (SMD: -0.58; 95 % CI: -0.80, -0.35) and anxiety symptoms (SMD: -0.39; 95 % CI: -0.58, -0.19). Subgroup analysis revealed that internet-based Cognitive Behavioral Therapy (iCBT), interventions lasting 7 to 10 weeks, and the use of the Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder-7 (GAD-7) scales, especially in other regions, had the most pronounced effects.

CONCLUSIONS

Digital intelligence interventions reduce depressive and anxious symptoms in older adults, supporting the development of evidence-based treatment guidelines in the digital era.

Older Adults Experience with a Layperson-Supported Digital Mental Health Intervention for Depression: Qualitative Insights on Engagement

OBJECTIVES

This qualitative study examines the experiences of older adults with Empower@Home, an older adult-centered, layperson-supported internet-based cognitive behavioral therapy (iCBT) program for depression, with a focus on engagement-related factors.

METHODS

Adults aged 50 or older with at least mild depressive symptoms were recruited from multiple resources. A random subset of participants was invited for a semi-structured qualitative interview during a post-intervention assessment conducted over the phone (N = 148). Interviews were recorded and transcribed verbatim. Transcripts were coded in a multi-phase, team-based approach utilizing inductive coding techniques, followed by thematic analysis to identify key themes.

RESULTS

Six key themes regarding engagement emerged: the importance of a structured, skills-based, and self-paced approach; the essential role of weekly coaching for accountability, web interface's ease of use and accessibility; narrative engagement dynamics; enhanced learning through multimodal instruction; and tailoring challenges in iCBT.

CONCLUSIONS

Older adult-centered, layperson-supported, and multimodal iCBT can effectively engage older adults in managing their mental health.

CLINICAL IMPLICATIONS

iCBT programs can be integrated into various community aging settings. By leveraging each setting's strengths and involving a range of professionals, these programs can play an important role in enhancing older adults' mental health.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/44210.

Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review

BACKGROUND

There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature.

OBJECTIVE

Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence.

METHODS

Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures.

RESULTS

A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics.

CONCLUSIONS

It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions.

Barriers and facilitators to acceptance and implementation of eMental-health intervention among older adults: A qualitative systematic review

Objective

Electronic mental health interventions are effective but not well promoted currently among older adults. This study sought to systematically review and summarize the barriers and facilitators of accepting and implementing electronic mental health interventions among older adults.

Methods

We comprehensively retrieved six electronic databases from January 2012 to September 2022: PubMed, Web of Science, Embase, Scopus, PsycINFO, and CINAHL. The JBI-QARI was used to assess the quality of the research methodology of each publication. Eligible studies underwent data coding and synthesis aligned to inductive and deductive methods. The Consolidated Framework for Implementation Research 2.0 was used as a deductive framework to guide a more structured analysis.

Results

The systematic review screened 4309 articles, 17 of which were included (eight with mixed methods and nine with qualitative methods). We identified and extracted the barriers and facilitators of accepting and implementing electronic mental health interventions among older adults: (1) innovation: technology challenges, optimized functions, and contents, security and privacy; (2) outer setting: community engagement and partnerships, financing; (3) inner setting: leadership engagement, available resources, incompatibility, intergenerational support, training and guidance; (4) individuals: perceptions, capability, motivation of older adults and healthcare providers; and (5) implementation process: recruit, external assistance, and team.

Conclusion

These findings are critical to optimizing, promoting, and expanding electronic mental health interventions among older adults. The systematic review also provides a reference for better evidence-based implementation strategies in the future.

Internet-delivered psychological interventions for older adults with depression: A scoping review

BACKGROUND

Depression is prevalent among older adults, and internet-delivered psychological interventions (IDPIs) have emerged as a promising solution.

AIM

To explore the landscape of IDPIs for late-life depression, examining current characteristics, psychotherapies, intervention strategies, facilitators, and barriers.

METHOD

Guided by a PRISMA-guided scoping review, we systematically searched five electronic databases.

RESULTS

25 relevant studies were identified. IDPIs were used for treatment, prevention, and assessment. Internet-based cognitive behavioral therapy was the most common psychotherapy. Seven strategies to provide tailored services include psychotherapy courses, professional involvement, mood and progress tracking, virtual community, timed reminders, additional learning resources, and gamification elements. Barriers contained cognitive impairment, low digital literacy, device inaccessibility, limited depression awareness, adherence issues, and acclimation time, while facilitators included prior treatment experience, real-life character stories, strong client-worker bonds, and integration into daily care routines.

CONCLUSION

IDPIs present an accessible and convenient avenue for older adults. Future directions suggest exploring minimalist interventions, diverse strategies, and optimized implementation to amplify IDPIs impact among this vulnerable group.

Digital interventions to reduce social isolation and loneliness in older adults: An evidence and gap map

Background

Social isolation and loneliness are more common in older adults and are associated with a serious impact on their well-being, mental health, physical health, and longevity. They are a public health concern highlighted by the COVID-19 pandemic restrictions, hence the need for digital technology tools to enable remotely delivered interventions to alleviate the impact of social isolation and loneliness during the COVID-19 restrictions.

Objectives

To map available evidence on the effects of digital interventions to mitigate social isolation and/or loneliness in older adults in all settings except hospital settings.

Search Methods

We searched the following databases from inception to May 16, 2021, with no language restrictions. Ovid MEDLINE, Embase, APA PsycInfo via Ovid, CINAHL via EBSCO, Web of Science via Clarivate, ProQuest (all databases), International Bibliography of the Social Sciences (IBSS) via ProQuest, EBSCO (all databases except CINAHL), Global Index Medicus, and Epistemonikos.

Selection Criteria

Titles and abstracts and full text of potentially eligible articles were independently screened in duplicate following the eligibility criteria.

Data Collection and Analysis

We developed and pilot tested a data extraction code set in Eppi-Reviewer and data were individually extracted and coded based on an intervention-outcome framework which was also used to define the dimensions of the evidence and gap map.

Main Results

We included 200 articles (103 primary studies and 97 systematic reviews) that assessed the effects of digital interventions to reduce social isolation and/or loneliness in older adults. Most of the systematic reviews (72%) were classified as critically low quality, only 2% as high quality and 25% were published since the COVID-19 pandemic. The evidence is unevenly distributed with clusters predominantly in high-income countries and none in low-income countries. The most common interventions identified are digital interventions to enhance social interactions with family and friends and the community via videoconferencing and telephone calls. Digital interventions to enhance social support, particularly socially assistive robots, and virtual pets were also common. Most interventions focused on reducing loneliness and depression and improving quality of life of older adults. Major gaps were identified in community level outcomes and process indicators. No included studies or reviews assessed affordability or digital divide although the value of accessibility and barriers caused by digital divide were discussed in three primary studies and three reviews. Adverse effects were reported in only two studies and six reviews. No study or review included participants from the LGBTQIA2S+ community and only one study restricted participants to 80 years and older. Very few described how at-risk populations were recruited or conducted any equity analysis to assess differences in effects for populations experiencing inequities across PROGRESS-Plus categories.

Authors' Conclusions

The restrictions placed on people during the pandemic have shone a spotlight onto social isolation and loneliness, particularly for older adults. This evidence and gap map shows available evidence on the effectiveness of digital interventions for reducing social isolation or loneliness in older adults. Although the evidence is relatively large and recent, it is unevenly distributed and there is need for more high-quality research. This map can guide researchers and funders to consider areas of major gaps as priorities for further research.

Standardising the role of a digital navigator in behavioural health: a systematic review

As the number and availability of digital mental health tools increases, patients and clinicians see benefit only when these tools are engaging and well integrated into care. Digital navigators-ie, members of health-care teams who are dedicated to supporting patient use of digital resources-offer one solution and continue to be piloted in behavioural health; however, little is known about the core features of this position. The aims of this systematic review were to assess how digital navigators are implemented in behavioural health, and to provide a standardised definition of this position. In January, 2023, we conducted a systematic literature search resulting in 48 articles included in this systematic review. Results showed high heterogeneity between four attributes of digital navigators: training specifications, educational background, frequency of communication, and method of communication with patients. Reported effect sizes for depression and anxiety were medium to large, but could not be synthesised due to study heterogeneity and small study sample size. This systematic review was registered with PROSPERO (CRD42023391696). Results suggest that digital navigator support can probably increase access to, engagement with, and clinical integration of digital health technology, with standards for training and defined responsibilities now emerging.

Effects of digital psychotherapy for depression and anxiety: A systematic review and bayesian network meta-analysis

OBJECTIVE

To evaluate the effectiveness of digital psychotherapies for depression and anxiety. We conducted a systematic review and network meta-analyses (NMA) to make comparisons of digital psychotherapies.

METHODS

A bayesian NMA was conducted in this study. The databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and CINAL were searched for all eligible randomized controlled trials (RCTs) published from Jan 1, 2012 to Oct 1, 2022. We used the Cochrane Collaboration's Risk of bias tool for quality assessment. The primary outcomes were set as a standardized mean difference model in efficacy to describe continuous outcomes. We used STATA and WinBUGS to conduct a bayesian network meta-analysis of all interventions based on a random-effects model. This study was registered with PROSPERO, number CRD42022374558.

RESULTS

From the retrieved 16,750 publications, we included 72 RCTs (13,096 participants) with the overall medium quality and above. In terms of depression scale, cognitive behavioral therapy (CBT) was more effective than TAU (SMDs 0.53) and NT (SMDs 0.98). In terms of anxiety scale, CBT (SMDs 0.68; SMDs 0.72) and exercise therapy (ERT) (SMDs 1.01; SMDs 1.05) were more effective than TAU and NT.

LIMITATIONS

Uneven quality of literature, simple network, and subjective judgment.

CONCLUSION

Based on NMA results, we suggest that CBT, which is the most commonly used digital technology, should be preferred among digital psychotherapy for relieving depression and anxiety symptoms. Digital exercise therapy is an effective strategy to relieve some anxiety problems in the context of COVID-19.

Web-Based Cognitive Behavioral Therapy for Depression Among Homebound Older Adults: Development and Usability Study

BACKGROUND

Homebound older adults are a high-risk group for depression. However, many of them face barriers to accessing evidence-supported mental health treatments. Digital mental health interventions can potentially improve treatment access, but few web-based interventions are explicitly tailored for depression in older adults.

OBJECTIVE

This paper describes the development process of Empower@Home, a web-delivered intervention for depression in homebound older adults that is based on cognitive behavioral therapy, and reports on the outcomes of usability studies.

METHODS

Empower@Home was developed in collaboration with community agencies, stakeholders, and older adults, guided by user-centered design principles. User needs were assessed through secondary data analysis, demographic and health profiles from administrative data, and interviews and surveys of community partners. A comparative usability evaluation was conducted with 10 older adults to assess the usability of Empower@Home compared to 2 similar programs. Field testing was conducted with 4 end users to detect additional usability issues.

RESULTS

Feedback and recommendations from community partners heavily influenced the content and design of Empower@Home. The intervention consists of 9 sessions, including psychoeducation and an introduction to cognitive behavioral therapy skills and tools through short video clips, in-session exercises, an animated storyline, and weekly out-of-session home practice. A printed workbook accompanies the web-based lessons. In comparative usability testing (N=10), Empower@Home received a System Usability Scale score of 78 (SD 7.4), which was significantly higher than the 2 comparator programs (t9=3.28; P=.005 and t9=2.78; P=.011). Most participants, 80% (n=8), preferred Empower@Home over the comparators. In the longitudinal field test (n=4), all participants reported liking the program procedures and feeling confident in performing program-related tasks. The single-subject line graph showed an overall downward trend in their depression scores over time, offering an encouraging indication of the intervention's potential effects.

CONCLUSIONS

Collaboration with community stakeholders and careful consideration of potential implementation issues during the design process can result in more usable, engaging, and effective digital mental health interventions.

Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review

BACKGROUND

New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness.

OBJECTIVE

This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy.

METHODS

We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study.

RESULTS

This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability.

CONCLUSIONS

Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations.

CBT-informed psychological interventions for adult patients with anxiety and depression symptoms: A narrative review of digital treatment options

BACKGROUND

Across a range of age, educational and clinical characteristics, adults experiencing depression and anxiety already use digital technology to manage their symptoms. Although several reviews and meta-analyses indicated feasibility and efficacy for adults with depression and anxiety, digital treatments are poorly accessed and disseminated. This review illustrates potentials and limitations of interventions that specifically leveraged unique features of digital technology and were grounded in the principles of Cognitive Behavioral Therapy (CBT).

METHODS

This systematic review followed the PRISMA guidelines. An electronic database search was conducted in October 2021. Peer-reviewed, English-language studies were included if i) they reported data from RCTs for adults aged 18+ who engaged with CBT-informed digital interventions targeting primarily depression and anxiety; ii) they used at least PHQ-9 or GAD-7 as standardized and validated assessment self-report measures for depression and anxiety.

RESULTS

Findings from 35 RCTs examining 33 interventions (25 internet-based, 6 mobile-based, a2 mobile/web) are discussed. The quality of the evidence differed widely as many small-scale RCTs reported only short-term feasibility and preliminary efficacy. Effects of CBT-informed digital interventions were substantially larger when compared to waitlist than active control conditions. Greater therapeutic benefits were observed for interventions that offered clinical assistance or were used in combination with other treatments.

CONCLUSIONS

CBT-informed digital interventions have accumulated enough scientific evidence to be positioned today as: i) a low-intensity tool for those with subclinical levels of symptoms; ii) a first step in a stepped-care approach to service delivery iii) a low-cost, easily accessible option for targeted preventive programs.

Understanding the Role of Support in Digital Mental Health Programs With Older Adults: Users' Perspective and Mixed Methods Study

BACKGROUND

Digital mental health interventions have the potential to increase mental health support among isolated older adults. However, the older adult population can experience several barriers to accessing and using digital health resources and may need extra support to experience its benefits.

OBJECTIVE

This paper aimed to understand what older adults experience as an important aspect of support during engagement in a digital mental health program. The program entailed 3 months of staff support to participate in digital literacy training and engage with the digital mental health platform myStrength, which offers support for a range of mental health challenges, including depression and anxiety.

METHODS

A total of 30 older adults participated in surveys and interviews to assess their experience of participating in a digital mental health program provided by county mental health services. As part of the program, participants attended 4 classes of digital literacy training, had access to the digital mental health platform myStrength for 2 months with staff support (and 10 months after the program without support), and received support from program staff during the entire 3-month program. Survey data were analyzed using descriptive statistics, and interview data were analyzed using thematic analysis.

RESULTS

A thematic analysis of the interview data revealed that participants valued ongoing support in 3 main areas: technical support to assist them in using technology, guided support to remind them to use myStrength and practice skills they had learned, and social support to enable them to connect with others through the program. Furthermore, participants reported that social connections was the most important aspect of the program and that they were mainly motivated to participate in the program because it was recommended to them by trusted others such as a community partner or because they believed it could potentially help others.

CONCLUSIONS

Our findings can be used to inform the design of future digital mental health programs for older adults who may have unique support needs in terms of dedicated technical support and ongoing guided support to use technology and social support to increase social connectedness.

Volunteer peer support frameworks supporting older women living alone

Volunteer peer support is an approach that enables a supportive connection between volunteers and a sub-set of community members with shared experiences or interests. To implement co-designed strategies to support older women to maintain independence and optimise wellbeing in Australia, a volunteer peer support approach was proposed. There was limited literature describing volunteer peer support frameworks to underpin interventions of this kind; and given the increasing desire for engagement of individuals and communities, articulation of the key components of such a framework is warranted. In this paper, we define volunteers and peer support, and outline existing frameworks for volunteering and peer support. We then describe the volunteer peer support framework developed for this intervention, outlining the key requirements. This information will enable others to develop an effective and sustainable structure for peer support volunteer services.

Meeting Young Adults' Social Support Needs across the Health Behavior Change Journey: Implications for Digital Mental Health Tools

In pursuit of mental wellness, many find that behavioral change is necessary. This process can often be difficult but is facilitated by strong social support. This paper explores the role of social support across behavioral change journeys among young adults, a group at high risk for mental health challenges, but with the lowest rates of mental health treatment utilization. Given that digital mental health tools are effective for treating mental health conditions, they hold particular promise for bridging the treatment gap among young adults, many of whom, are not interested in - or cannot access - traditional mental healthcare. We recruited a sample of young adults with depression who were seeking information about their symptoms online to participate in an Asynchronous Remote Community (ARC) elicitation workshop. Participants detailed the changing nature of social interactions across their behavior change journeys. They noted that both directed and undirected support are necessary early in behavioral change and certain needs such as informational support are particularly pronounced, while healthy coping partnerships and accountability are more important later in the change process. We discuss the conceptual and design implications of our findings for the next generation of digital mental health tools.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

Design, implementation and evaluation of informal home care support intervention program for lonely older adults in the community: Protocol for a feasibility study

BACKGROUND

Providing lonely older adults with informal home care services is important to improving their health and quality of life. The study aims to evaluate the feasibility of design, implementation and evaluation of an informal home care support intervention program (HoSIP) for community-dwelling lonely older adults in Gorgan, Iran.

METHOD/DESIGN

This feasibility study is a mixed-method with a concurrent nested design. Lonely older adults will be enrolled as the HoSIP intervention group and will receive 12-weeks of informal home care service by peer supporters. The purpose of this feasibility study is to determine the recruitment capability and resulting sample characteristics, data collection procedure and outcome measures, the acceptability and suitability of the intervention and study procedures, the resource and ability to manage the study and intervention, and preliminary evaluation of participant response to intervention. Primary outcomes including participant feelings of loneliness, quality of life, general health, social network, social support, and self-care ability, will be assessed at baseline and post-intervention for the intervention and control groups. Semi-structured interviews will be conducted immediately after the intervention using content qualitative approach to describe participants' experiences with HoSIP.

DISCUSSION

Through this study we will examine the feasibility of delivering informal home care services to community-dwelling lonely older adults in a developing country through employing a concurrent nested mixed-method design.

TRIAL REGISTRATION

IRCT20190503043455N.

Randomized controlled trial of Sunnyside: Individual versus group-based online interventions to prevent postpartum depression

BACKGROUND

Postpartum depression (PPD) is a serious mental health problem that has a prevalence rate of nearly 20% in the first three months after delivery. The purpose of this study was to evaluate the benefit of Sunnyside, an internet-based cognitive-behavioral intervention, delivered in a group format compared to the same intervention delivered individually for the prevention of PPD.

METHOD

210 people between 20- and 28-weeks gestation and who scored between 5 and 14 on the PHQ-8 and who did not meet criteria for major depression were recruited online. The Inventory of Depression and Anxiety Symptoms (IDAS), the Hamilton Rating Scale for Depression (HAMD), and the depression and anxiety modules of the MINI were obtained at baseline, post-treatment, and 12-weeks postpartum. Intervention adherence was measured by site usage.

RESULTS

Across self-report and interview measures of depression there were no significant differences in outcome between the group and the individual versions of the program. Rates of major depression and generalized anxiety disorder in the postpartum period were low and adherence to the conditions was similarly high. Participants in the individual condition were significantly more satisfied than participants in the group condition (p < 0.05).

LIMITATIONS

The sample was predominantly white (85%) and recruited online, which may limit generalizability.

CONCLUSIONS

The group intervention was not more effective than the individual intervention. However, ignoring groups, many measures improved over time. The results of this study provide evidence that mood symptoms improve when participating in an online preventive intervention for postpartum depression.

Effect of distinct psychological interventions on changes in self-reported distress, depression and loneliness among older adults during COVID-19

BACKGROUND

Older adults have been considered a primary at-risk population during the coronavirus disease 2019 (COVID-19) pandemic, and many efforts have been and still are directed toward supporting them and enhancing their capacity to cope with the pandemic. Evidence shows that by enhancing proactive coping abilities through psychological interventions, in which cognitive-behavioral and mindfulness techniques are taught and practiced effectively, these interventions have supported older adults throughout the pandemic. However, the underlying mechanisms by which specific intervention components affect various mental states such as distress, depression and loneliness among older adults remain unclear and warrant investigation.

AIM

To determine the effect of an intervention using cognitive-behavioral and mindfulness techniques on changes in distress, depression and loneliness.

METHODS

We performed a secondary analysis on data from a previous study in which community-dwelling older adults attended a short-term, internet-based intervention during the first COVID-19 wave in Israel. The intervention included seven sessions during which various cognitive-behavioral and mindfulness techniques were learned and practiced. In-session changes in psychological distress were measured using the Subjective Units of Distress Scale (SUDS), which participants rated at the beginning and end of each session. Participants also filled out questionnaires that evaluated levels of depression [Patient Health Ques-tionnaire (PHQ-9)] and loneliness (UCLA loneliness Scale) prior to and after the entire intervention process. The effect of in-session changes in the SUDS on changes in post-intervention depression and loneliness levels were assessed, as a proxy for distinct technique effectiveness.

RESULTS

The findings indicated in-session differences in terms of a decrease in psychological distress (SUDS). Sessions that included relaxation exercises and guided imagery, as well as sessions that included cognitive restructuring and mindfulness meditation, demonstrated the largest decreases in in-session psychological distress (≥ 35%). Two multivariate regression models, one for levels of post-intervention depression (PHQ-9 score) and the other for levels of post-intervention loneliness (UCLA loneliness score), were fitted. The results revealed two statistically significant explanatory variables for depression: The SUDS difference for sessions in which cognitive restructuring and mindfulness meditation were practiced, beta = -0.25, 95%CI: -1.23 to -0.1, and the pre-intervention level of depression, beta = 0.62, 95%CI: 0.37-0.75. The second model for loneliness revealed only one significant explanatory variable: The SUDS difference for sessions in which relaxation and guided imagery were practiced, beta = 0.41, 95%CI: 0.14-0.65.

CONCLUSION

Different psychological techniques seem to have different effects on distress, loneliness and depression. Understanding the pathways by which distinct techniques affect negative mental symptoms has implications for future intervention design.

Remotely supervised home-based online chair yoga intervention for older adults with dementia: Feasibility study

BACKGROUND

and Purpose: Social isolation and caregiver burden call for an innovative way to deliver a chair yoga (CY) intervention to older adults with dementia who cannot travel to a community center. During a remotely supervised CY session, the yoga instructor can monitor each participant's pose and correct poses to optimize efficacy of CY and reduce chances of injury. This study assessed the feasibility of a remotely supervised online CY intervention for older adults with dementia and explored the relationship between CY and clinical outcomes: pain interference, mobility, risk of falling, sleep disturbance, autonomic reactivity, and loneliness.

METHODS

Using a one-group pretest/posttest design, a home-based CY intervention was delivered remotely to 10 older adults with dementia twice weekly in 60-minute sessions for 8 weeks. Psychosocial and physiological (i.e., cardiac) data were collected remotely at baseline, mid-intervention, and post-intervention.

RESULTS

The results indicated that remotely supervised online CY is a feasible approach for managing physical and psychological symptoms in socially isolated older adults with dementia, based on retention (70%) and adherence (87.5%), with no injury or other adverse events. While there were no significant findings for pain interference, mobility, sleep, or social loneliness longitudinally, emotional loneliness showed a significant increase, F(1.838, 11.029) = 6.293, p = .016, η² = 0.512, from baseline to post-intervention. Although participants were socially connected to other participants via a videoconferencing platform, emotional loneliness increased during the pandemic period.

CONCLUSION

A home-based remotely supervised online CY is a feasible approach for socially isolated older adults with dementia who are unable to travel to a facility.

Loneliness in older people and COVID-19: Applying the social identity approach to digital intervention design

The COVID-19 pandemic is worsening loneliness for many older people through the challenges it poses in engaging with their social worlds. Digital technology has been offered as a potential aid, however, many popular digital tools have not been designed to address the needs of older adults during times of limited contact. We propose that the Social Identity Model of Identity Change (SIMIC) could be a foundation for digital loneliness interventions. While SIMIC is a well-established approach for maintaining wellbeing during life transitions, it has not been rigorously applied to digital interventions. There are known challenges to integrating psychological theory in the design of digital technology to enable efficacy, technology acceptance, and continued use. The interdisciplinary field of Human Computer Interaction has a history of drawing on models originating from psychology to improve the design of digital technology and to design technologies in an appropriate manner. Drawing on key lessons from this literature, we consolidate research and design guidelines for multidisciplinary research applying psychological theory such as SIMIC to digital social interventions for loneliness.

The Effectiveness of Assistive Technologies for Older Adults and the Influence of Frailty: Systematic Literature Review of Randomized Controlled Trials

Background

The use of assistive technologies (ATs) to support older people has been fueled by the demographic change and technological progress in many countries. These devices are designed to assist seniors, enable independent living at home or in residential facilities, and improve quality of life by addressing age-related difficulties.

Objective

We aimed to evaluate the effectiveness of ATs on relevant outcomes with a focus on frail older adults.

Methods

A systematic literature review of randomized controlled trials evaluating ATs was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Ovid Medline, PsycINFO, SocIndex, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and IEEEXplore databases were searched from January 1, 2009, to March 15, 2019. ATs were included when aiming to support the domains autonomy, communication, or safety of older people with a mean age ≥65 years. Trials performed within a laboratory setting were excluded. Studies were retrospectively categorized according to the physical frailty status of participants.

Results

A total of 19 trials with a high level of heterogeneity were included in the analysis. Six device categories were identified: mobility, personal disease management, medication, mental support, hearing, and vision. Eight trials showed significant effectiveness in all or some of the primary outcome measures. Personal disease management devices seem to be the most effective, with four out of five studies showing significant improvement of disease-related outcomes. Frailty could only be assessed for seven trials. Studies including participants with significant or severe impairment showed no effectiveness.

Conclusions

Different ATs show some promising results in well-functioning but not in frail older adults, suggesting that the evaluated ATs might not (yet) be suitable for this subgroup. The uncertainty of the effectiveness of ATs and the lack of high-quality research for many promising supportive devices were confirmed in this systematic review. Large studies, also including frail older adults, and clear standards are needed in the future to guide professionals, older users, and their relatives.

Trial Registration

PROSPERO CRD42019130249; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130249

An overview of and recommendations for more accessible digital mental health services

Mental health concerns are common, and various evidence-based interventions for mental health conditions have been developed. However, many people have difficulty accessing appropriate mental health care and this has been exacerbated by the COVID-19 pandemic. Digital mental health services, such as those delivered by mobile phone or web-based platforms, offer the possibility of expanding the reach and accessibility of mental health care. To achieve this goal, digital mental health interventions and plans for their implementation must be designed with the end users in mind. In this Review, we describe the evidence base for digital mental health interventions across various diagnoses and treatment targets. Then, we explain the different formats for digital mental health intervention delivery, and offer considerations for their use across key age groups. We discuss the role that the COVID-19 pandemic has played in emphasizing the value of these interventions, and offer considerations for ensuring equity in access to digital mental health interventions among diverse populations. As healthcare providers continue to embrace the role that technology can play in broadening access to care, the design and implementation of digital mental healthcare solutions must be carefully considered to maximize their effectiveness and accessibility.

Efficacy of internet-based interventions for common mental disorder symptoms and psychosocial problems in older adults: A systematic review and meta-analysis

BACKGROUND

Although a high proportion of older adults suffer from common mental disorder symptoms and psychosocial problems, only a small number of older individuals seek psychological treatment. Internet-based interventions have the potential to bridge this treatment gap. However, while there is extensive literature on internet-based treatments in younger to middle-aged adults, research on older individuals is lacking.

OBJECTIVE

We aimed to summarize narratively and empirically the existing literature on the efficacy of internet-based interventions for the treatment of common mental disorder symptoms and psychosocial problems (loneliness, stress) in older individuals.

METHODS

This systematic review and meta-analysis was registered in PROSPERO (registration number: CRD42021235129). Systematic literature searches were conducted in PsycInfo, Ageline, Medline, CINHAL, and Psyndex. Studies were eligible for inclusion if they a) focused on older adults, b) assessed the efficacy of an internet-delivered psychological intervention, c) included a control condition and d) assessed common mental disorder symptoms or psychosocial problems as outcomes. Meta-analyses were conducted based on studies that included a passive, minimally active or placebo control condition to estimate pooled effects on overall symptom severity as well as on specific psychological outcomes.

RESULTS

11 Studies met inclusion criteria, with the majority of interventions focusing on depression or anxiety symptoms and being based on CBT principles. Significant large effect of internet-based interventions for older adults were found for overall symptom severity (depression, anxiety, PTSD, stress) as well as for depression symptom severity. No significant effects were found for anxiety symptom severity.

DISCUSSION

Our findings provide preliminary support that internet-based interventions might be a feasible and effective intervention method for the treatment of common mental disorder symptoms and stress in older adults. However, research in this area is still at an early stage. More studies are needed to shed light on the role of various treatment and patient characteristics in the efficacy of internet-delivered treatments.

Digital Ageism: Challenges and Opportunities in Artificial Intelligence for Older Adults

Artificial intelligence (AI) and machine learning are changing our world through their impact on sectors including health care, education, employment, finance, and law. AI systems are developed using data that reflect the implicit and explicit biases of society, and there are significant concerns about how the predictive models in AI systems amplify inequity, privilege, and power in society. The widespread applications of AI have led to mainstream discourse about how AI systems are perpetuating racism, sexism, and classism; yet, concerns about ageism have been largely absent in the AI bias literature. Given the globally aging population and proliferation of AI, there is a need to critically examine the presence of age-related bias in AI systems. This forum article discusses ageism in AI systems and introduces a conceptual model that outlines intersecting pathways of technology development that can produce and reinforce digital ageism in AI systems. We also describe the broader ethical and legal implications and considerations for future directions in digital ageism research to advance knowledge in the field and deepen our understanding of how ageism in AI is fostered by broader cycles of injustice.

Internet-Based Psychotherapy Intervention for Depression Among Older Adults Receiving Home Care: Qualitative Study of Participants' Experiences

BACKGROUND

Depression is common among homebound older adults. Internet-based cognitive behavioral therapy (iCBT) is a promising but understudied approach for treating depression among older adults with disabilities.

OBJECTIVE

This study aims to understand the experiences of homebound older adults who participated in a pilot feasibility trial of an iCBT for depression.

METHODS

The participants included 21 homebound older adults who participated in a generic iCBT program that was not specifically designed for older adults and 8 home care workers who assisted in the iCBT program. Informants completed semistructured individual interviews, which were transcribed verbatim and analyzed using methods informed by grounded theory. A hierarchical code structure of themes and subthemes was developed after an iterative process of constant comparisons and questionings of the initial codes. The data analysis was conducted by using dedoose, a web app for mixed methods research.

RESULTS

Three themes and various subthemes emerged related to participants' experience of the iCBT intervention, as follows: intervention impact, which involved subthemes related to participants' perceived impact of the intervention; challenges and difficulties, which involved subthemes on the challenges and difficulties that participants experienced in the intervention; and facilitators, which involved subthemes on the factors that facilitated intervention use and engagement.

CONCLUSIONS

iCBT is a promising intervention for homebound older adults experiencing depression. Home care workers reported improved relationships with their clients and that the program did not add a burden to their duties. Future programs should involve accessible technical features and age-adapted content to improve user experience, uptake, and adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04267289; https://clinicaltrials.gov/ct2/show/NCT04267289.

Teaching and Practicing Cognitive-Behavioral and Mindfulness Skills in a Web-Based Platform among Older Adults through the COVID-19 Pandemic: A Pilot Randomized Controlled Trial

The outbreak of the COVID-19 pandemic has led to an acceleration in the development of web-based interventions to alleviate related mental health impacts. The current study explored the effects of a short-term digital group intervention aimed at providing cognitive behavioral and mindfulness tools and skills to reduce loneliness and depression and to increase social support among older adults in Israel. This pilot randomized controlled trial included community-dwelling older adults (n = 82; aged between 65–90 years; 80% female) who were randomized either to an intervention group (n = 64) or a wait-list control group (n = 18). The intervention included seven online sessions, over 3.5 weeks. Depression, loneliness, and social support measures were administered at baseline, immediately post-intervention, and at 1-month follow-up. Repeated measures ANOVA revealed statistically and clinically significant reductions in depression in the intervention group, with results maintained at one-month follow-up. Loneliness levels also significantly decreased post-intervention; however, this benefit was not maintained at one-month follow-up. Social support slightly increased both post-intervention and 1-month follow-up—but these changes were not statistically significant. There were no overall changes for the wait-list control group. Our intervention provided promising evidence regarding the effectiveness of an online group intervention to alleviate mental health effects and to promote the coping of older adults during the COVID-19 pandemic. This relatively simple model can be effectively utilized by communities globally to help connect lonely and isolated older inhabitants, both during the pandemic and in more routine times.

A Newly Developed Online Peer Support Community for Depression (Depression Connect): Qualitative Study

Background

Internet support groups enable users to provide peer support by exchanging knowledge about and experiences in coping with their illness. Several studies exploring the benefits of internet support groups for depression have found positive effects on recovery-oriented values, including empowerment. However, to date, little attention has been paid to user narratives.

Objective

This study aims to capture the user perspective on an online peer support community for depression with a focus on the modes of user engagement and the benefits users derive from participation in the forum.

Methods

In this qualitative study, we conducted 15 semistructured interviews with users of Depression Connect, a newly developed online peer support community for individuals with depression. Combining a concept-driven and a data-driven approach, we aimed to gain insight into what users value in our Depression Connect platform and whether and how the platform promotes empowerment. We performed a thematic analysis to explore the merits and demerits reported by users by using theoretical concepts widely used in internet support group research. In the subsequent data-driven analysis, we sought to understand the relationship between different styles of user engagement and the participants’ experiences with the use of Depression Connect. Data analysis consisted of open, axial, and selective coding. To include as diverse perspectives as possible, we opted for purposive sampling. To verify and validate the (interim) results, we included negative cases and performed member checks.

Results

We found participation in Depression Connect contributes to a sense of belonging, emotional growth, self-efficacy, and empowerment. “Getting too caught up” was the most frequently reported negative aspect of using Depression Connect. The deployment and development of three participation styles (ie, reading, posting, and responding) affected the perceived benefits of Depression Connect use differentially, where the latter style was central to enhancing empowerment. “Being of value to others” boosted the users’ belief in their personal strength. Finally, Depression Connect was predominantly used to supplement offline support and care for depression, and it mainly served as a safe environment where members could freely reflect on their coping mechanisms for depression and exchange and practice coping strategies.

Conclusions

Our findings shed new light on user engagement processes on which internet support groups rely. The online community primarily served as a virtual meeting place to practice (social) skills for deployment in the offline world. It also allowed the members to learn from each other’s knowledge and experiences and explore newly gained insights and coping skills.

Adapting a whole health model to home-based primary care: Bridging person-driven priorities with veteran and family-centered geriatric care

Through the integration of Whole Health for Life into the Department of Veterans Affairs (VA) health care system, the VA aims to transform health care delivery from a disease management approach to one that embraces person-centered care. The home-based primary care (HBPC) program is a care model that, within the VA, provides holistic primary care services to homebound veterans with multiple chronic medical conditions, mental health issues, and functional declines. These veterans may have limited access to VA programs delivered in a traditional outpatient format. This article describes adaptations to the whole health model of care that could improve its accessibility and applicability to HBPC veterans, caregivers, and the interdisciplinary teams that serve this population. These modifications are informed by whole-person geriatric and gerontological and family-systems theories and address population-based differences in the focus and approach to care. The focus on care is expanded to (a) reflect the importance of attending to caregiver needs and well-being and (b) shift from a preventative model to one that prioritizes resilience and maintenance. The approach to care emphasizes alternative modes of delivery, adaptations to interventions, and integration of geriatric-specific medical considerations into the self-care domains and more directly centers the collaboration between family, the VA, and community partners. This adapted model also addresses the unique needs of health care teams providing in-home services to medically complex veterans and offers suggestions for enhancing self-care and preventing burnout. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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

Digital Health Interventions in Prevention, Relapse, and Therapy of Mild and Moderate Depression: Scoping Review

BACKGROUND

Depression is a major cause for disability worldwide, and digital health interventions are expected to be an augmentative and effective treatment. According to the fast-growing field of information and communication technologies and its dissemination, there is a need for mapping the technological landscape and its benefits for users.

OBJECTIVE

The purpose of this scoping review was to give an overview of the digital health interventions used for depression. The main goal of this review was to provide a comprehensive review of the system landscape and its technological state and functions, as well as its evidence and benefits for users.

METHODS

A scoping review was conducted to provide a comprehensive overview of the field of digital health interventions for the treatment of depression. PubMed, PSYNDEX, and the Cochrane Library were searched by two independent researchers in October 2020 to identify relevant publications of the last 10 years, which were examined using the inclusion and exclusion criteria. To conduct the review, we used Rayyan, a freely available web tool.

RESULTS

In total, 65 studies were included in the qualitative synthesis. After categorizing the studies into the areas of prevention, early detection, therapy, and relapse prevention, we found dominant numbers of studies in the area of therapy (n=52). There was only one study for prevention, 5 studies for early detection, and 7 studies for relapse prevention. The most dominant therapy approaches were cognitive behavioral therapy, acceptance and commitment therapy, and problem-solving therapy. Most of the studies revealed significant effects of digital health interventions when cognitive behavioral therapy was applied. Cognitive behavioral therapy as the most dominant form was often provided through web-based systems. Combined interventions consisting of web-based and smartphone-based approaches are increasingly found.

CONCLUSIONS

Digital health interventions for treating depression are quite comprehensive. There are different interventions focusing on different fields of care. While most interventions can be beneficial to achieve a better depression treatment, it can be difficult to determine which approaches are suitable. Cognitive behavioral therapy through digital health interventions has shown good effects in the treatment of depression, but treatment for depression still stays very individualistic.

Social Isolation and Loneliness during COVID-19 Lockdown: Associations with Depressive Symptoms in the German Old-Age Population

Lockdowns during the COVID-19 pandemic increase the risk of social isolation and loneliness, which may affect mental wellbeing. Therefore, we aimed to investigate associations between social isolation and loneliness with depressive symptoms in the German old-age population during the first COVID-19 lockdown. A representative sample of randomly selected individuals at least 65 years old (n = 1005) participated in a computer-assisted standardized telephone interview in April 2020. Sociodemographic data, aspects of the personal life situation, attitudes towards COVID-19 and standardized screening measures on loneliness (UCLA 3-item loneliness scale), depression (Brief Symptom Inventory/BSI-18), and resilience (Brief Resilience Scale/BRS) were assessed. Associations were inspected using multivariate regression models. Being lonely, but not isolated (β = 0.276; p < 0.001) and being both isolated and lonely (β = 0.136; p < 0.001) were associated with higher depressive symptoms. Being isolated, but not lonely was not associated with depressive symptoms. Thus, the subjective emotional evaluation, i.e., feeling lonely, of the social situation during lockdown seems more relevant than the objective state, i.e., being isolated. Normal (β = -0.203; p < 0.001) and high resilience (β = -0.308; p < 0.001) were associated with lower depressive symptoms across groups. Therefore, strengthening coping skills may be a support strategy during lockdowns, especially for lonely older individuals.

An Exploratory Brief Head-To-Head Non-Inferiority Comparison of an Internet-Based and a Telephone-Delivered CBT Intervention for Adults with Depression

BACKGROUND

Telephone-administered psychotherapy (tCBT) and internet-based treatments (iCBT) may overcome barriers to mental health treatment. TCBT has demonstrated efficacy similar to traditional psychotherapy, however, few studies have compared iCBT to efficacious interventions. This exploratory study examined the noninferiority of iCBT relative to tCBT. We also explored pretreatment moderators of outcome and assessed treatment dropout.

METHODS

As a secondary exploratory analysis of a 304-participant randomized noninferiority trial, we compared iCBT, the first level of a stepped-care intervention, with tCBT on depression outcome after 5 weeks of treatment (prior to stepping). Multiple linear regression models were fit to examine moderators of 5-week depression. Differences in dropout were examined using Kaplan-Meier survival analysis.

RESULTS

After 5 weeks of treatment, both interventions significantly reduced depression severity. The effect size difference between the two interventions was d=0.004 [90% CI=-0.19 to 0.19]; the CI did not cross the non-inferiority margin. Pretreatment depression was significantly associated with depression at week 5. The relationship between cognitive strategy usefulness and depression at week 5 differed between interventions, controlling for pretreatment depression. There was no significant difference in dropout between interventions.

LIMITATIONS

Given the stepped-care trial design, iCBT and tCBT could not be compared at the end of treatment or follow-up. Analyses were exploratory and should be interpreted with caution.

CONCLUSIONS

A large sample, powered for noninferiority, found iCBT no less efficacious than tCBT at reducing depression symptoms after five weeks of treatment.

Knowledge, Responsibilities, and Peer Advice From Care Partners of Patients With Parkinson Disease Psychosis

Introduction: Care partners (CPs) of individuals with Parkinson disease psychosis (PDP) experience increased strain and rely on informal support networks. The objective of this study was to characterize CP responsibilities, sources of support, and peer advice.

Methods: This was a mixed-methods cross-sectional study. The sample was recruited from the online Fox Insight study cohort. CPs who indicated their care recipient suffered hallucinations and/or delusions were administered a questionnaire regarding their caregiving experience to person with PDP. A free-text question asked CPs to give advice to a hypothetical peer CP. Responses to multiple-choice questions were tabulated; responses to the free-text question were grouped into advice categories.

Results: 145 CP of individuals with PDP were included in this analysis, mean age (standard deviation, SD) 66.4 (9.4) years; 110 (75.9%) were women. Most (115, 79.3%) provided caregiving on a daily basis, with a range of responsibilities. Only 16 (11%) learned about PDP from a physician; communication challenges included perceived embarrassment or having to prioritize other issues in a limited appointment time. The most common peer advice was to alert the care recipient's neurologist (n = 38, 30.4%); only 8 (6.4%) suggested medication changes.

Conclusion: CPs face challenges with clinician communication and learn about psychosis from a variety of informal sources. Few CPs advocate for medications to control PDP, instead preferring non-pharmacological management strategies. Peer advice favored alerting the care recipient's physician, suggesting that CPs do desire more information from the medical team.

Primary Care Peer-Supported Internet-Mediated Psychological Treatment for Adults With Anxiety Disorders: Mixed Methods Study

Background

The effect of internet-delivered cognitive behavioral therapy (iCBT) on anxiety in adults is well-known. However, patient dropouts and poor adherence to treatment are common. Feelings of belonging and empowerment from the treatment might be key to the completion of iCBT. Peer support workers are people with a personal experience of mental health problems, trained to provide professional support to people who require mental health care.

Objective

This study aims to assess patient experiences; the feasibility, safety, and acceptability; and preliminary effectiveness on anxiety and depression, empowerment, and adherence to treatment in an 8-week peer-supported iCBT program for patients with anxiety disorders treated in primary care.

Methods

This was a single-arm mixed methods feasibility study. Participants were patients referred to a central unit for iCBT in primary care. Quantitative data were collected pre-, post-, and 3 months postintervention. Qualitative data were collected through semistructured interviews.

Results

A total of 9 participants completed the quantitative outcome assessment. Statistically significant improvements were observed in perceived empowerment at a 3-month follow-up, and significant decreases in anxiety, depression, and psychological distress at the end of the treatment were maintained at a 3-month follow-up. In total, 8 of the 9 patients showed improvement in the severity of their symptoms of anxiety. Adherence to treatment was good among the participants. No serious adverse events were reported. Eight participants were enrolled in the qualitative analysis. The qualitative results showed 3 main themes: (1) real contact in an online world, (2) empowering experiences, and (3) being behind the wheel. Qualitative results largely emphasized the personal relationship and supported the acceptability of adding peer support to iCBT.

Conclusions

Peer support in digital treatment seems to be a safe and acceptable intervention. The preliminary results suggest the effectiveness of peer support on patient empowerment, anxiety, depression, psychological distress, and adherence to treatment. The results indicate the need for future studies to evaluate the effect of adding peer support to iCBT in larger randomized controlled trials.

Internet-delivered cognitive behavioral therapies for late-life depressive symptoms: a systematic review and meta-analysis

Background: This study aimed to review and synthesize evidence related to the effectiveness of internet-based cognitive behavioral therapy (iCBT) for reducing depressive symptoms in older adults.Method: The authors conducted a systematic review of intervention studies testing iCBT for symptoms of depression in older adults. An initial search of PubMed, PsychINFO, and Web of Science was undertaken, followed by a manual search of reference lists of the relevant articles. The Cochrane Risk of Bias Tool was used to appraise study quality. The mean effect size for included studies was estimated in a random effects model. Meta-regression was used to examine potential moderators of effect sizes.Results: Nine studies met the inclusion criteria, including 1272 participants averaging 66 years of age. The study design included randomized controlled trials (k = 3), controlled trials without randomization (k = 2), uncontrolled trials (k = 2), and naturalistic evaluation (k = 2). Seven studies tested iCBT with some level of therapist involvement and 2 examined self-guided iCBT. Six studies tested interventions specifically adapted for older adults. The mean within-group effect size was 1.27 (95% CI = 1.09, 1.45) and the mean between-group effect size was 1.18 (95% CI = 0.63, 1.73). Participants' age was negatively associated with within-group effect sizes (b = -0.06, p = .016).Conclusions: iCBT is a promising approach for reducing depressive symptoms among older adults with mild to moderate depressive symptoms. However, studies involving older adults in iCBT trials were limited, had considerable heterogeneity, and were of low quality, calling for more studies with rigorous designs to produce a best-practice guideline.

A Systematic Review on Technology-Supported Interventions to Improve Old-Age Social Wellbeing: Loneliness, Social Isolation, and Connectedness

Background

This review studies technology-supported interventions to help older adults, living in situations of reduced mobility, overcome loneliness, and social isolation. The focus is on long-distance interactions, investigating the (i) challenges addressed and strategies applied; (ii) technology used in interventions; and (iii) social interactions enabled.

Methods

We conducted a search on Elsevier's Scopus database for related work published until January 2020, focusing on (i) intervention studies supported mainly by technology-mediated communication, (ii) aiming at supported virtual social interactions between people, and (iii) evaluating the impact of loneliness or social isolation.

Results

Of the 1178 papers screened, 25 met the inclusion criteria. Computer and Internet training was the dominant strategy, allowing access to communication technologies, while in recent years, we see more studies aiming to provide simple, easy-to-use technology. The technology used was mostly off-the-shelf, with fewer solutions tailored to older adults. Social interactions targeted mainly friends and family, and most interventions focused on more than one group of people. Discussion. All interventions reported positive results, suggesting feasibility. However, more research is needed on the topic (especially randomized controlled trials), as evidenced by the low number of interventions found. We recommend more rigorous methods, addressing human factors and reporting technology usage in future research.

Challenges and Benefits of an Internet-Based Intervention With a Peer Support Component for Older Adults With Depression: Qualitative Analysis of Textual Data

Background

Technological interventions provide many opportunities for improving the health and quality of life of older adults. However, interaction with new technologies can also cause frustration. Although these themes have been explored in extant research, much remains to be learned with regard to how the challenges of aging and technology use and the experiences of participating in a social and learning environment are interrelated.

Objective

This study aimed to perform a qualitative analysis of data collected from MoodTech, a pilot study of an internet-based intervention with a peer support component for older adults with symptoms of depression, to better understand the participants’ experience of using technological interventions, including the challenges and benefits that they experienced over the course of these interventions.

Methods

We employed an inductive qualitative analysis method based on grounded theory methodology and interpretative phenomenological analysis to analyze participant textual data. These textual data were of 3 main types: (1) assignments in which participants challenged their negative thoughts, (2) status updates, and (3) comments in the peer support component of the intervention.

Results

We have presented the results through 3 main themes: (1) the challenges of aging as seen through the participants’ comments, (2) the difficulties experienced by the participants in using MoodTech, and (3) the benefits they derived from participating.

Conclusions

This paper offers several contributions concerning study participants’ experiences with internet-based cognitive behavioral therapy (iCBT) interventions with a peer support component and design considerations for developing complex technological interventions that support the challenges participants experience due to aging and cognitive difficulties. First, technical issues encountered by older adults within the context of the intervention can interact with and exacerbate the insecurities they experience in life, and it is important to consider how intervention components might be designed to mitigate these issues. Second, peer support can be employed as a mechanism to facilitate communication, support, and collaborative problem solving among participants in an intervention. The insights from this paper can inform the design of iCBT interventions for older adults.

A randomized noninferiority trial evaluating remotely-delivered stepped care for depression using internet cognitive behavioral therapy (CBT) and telephone CBT

This trial examined whether a stepped care program for depression, which initiated treatment with internet cognitive behavioral therapy, including telephone and messaging support, and stepped up non-responders to telephone-administered cognitive behavioral therapy (tCBT), was noninferior, less costly to deliver, and as acceptable to patients compared to tCBT alone. Adults with a diagnosis of major depressive episode (MDE) were randomized to receive up to 20 weeks of stepped care or tCBT. Stepped care (n = 134) was noninferior to tCBT (n = 136) with an end-of-treatment effect size of d = 0.03 and a 6-month post-treatment effect size of d = -0.07 [90% CI 0.29 to 0.14]. Therapist time in stepped care was 5.26 (SD = 3.08) hours versus 10.16 (SD 4.01) for tCBT (p < 0.0001), with a delivery cost difference of $-364.32 [95% CI $-423.68 to $-304.96]. There was no significant difference in pre-treatment preferences (p = 0.10) or treatment dropout (39 in stepped care; 27 in tCBT; p = 0.14). tCBT patients were significantly more satisfied than stepped care patients with the treatment they received (p < 0.0001). These findings indicate that stepped care was less costly to deliver, but no less effective than tCBT. There was no significant difference in treatment preference or completion, however satisfaction with treatment was higher in tCBT than stepped care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01906476.

Stepping Up: Predictors of 'Stepping' within an iCBT Stepped-Care Intervention for Depression

Internet-based cognitive behavioral therapy (iCBT) may overcome barriers to mental health care and has proven efficacious. However, this approach currently exists outside the existing mental health care delivery system. Stepped care is a proposed framework for integrating digital mental health (DMH) into health systems by initiating iCBT and "stepping up" care to a more intensive intervention should iCBT prove ineffective. This study explores pre-treatment factors associated with reaching stepping criteria among patients receiving iCBT. This exploratory analysis of a stepped care arm of a larger randomized trial examined participants who were stepped to a more intensive intervention if they did not respond to iCBT. The association of pre-treatment factors on stepping were examined using Kruskal-Wallis and Chi-square tests. One-fifth of the 151 participants met criteria for stepping within the 20-week treatment period. Only pre-treatment depression severity and treatment preference were associated with increased likelihood of stepping (p = 0.049 and 0.048, respectively). The low number of individuals who stepped provides support for iCBT as an effective, low intensity treatment for depression. The modest association of pre-treatment depression and preference to not receive iCBT may be useful in identifying patients who are less likely to respond.

A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial

BACKGROUND

Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions.

OBJECTIVES

This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes.

METHODS

User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum.

RESULTS

A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment.

CONCLUSIONS

Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy).