Attrition from self-directed interventions: investigating the relationship between psychological predictors, intervention content and dropout from a body dissatisfaction intervention

We Have Spent Time, Money, and Effort Making Self-Help Digital Mental Health Interventions: Is Anyone Going to Come to the Party?

Although efficacious psychotherapies exist, a limited number of mental health care providers and significant demand make their accessibility a fundamental problem. Clinical researchers, funders, and investors alike have converged on self-help digital mental health interventions (self-help DMHIs) as a low-cost, low-burden, and broadly scalable solution to the global mental health burden. Consequently, exorbitant financial and time-based resources have been invested in developing, testing, and disseminating these interventions. However, the public's assumed desirability for self-help DMHIs by experts has largely proceeded without question. This commentary critically evaluates whether self-help DMHIs can, and will, reach their purported potential as a solution to the public burden of mental illness, with an emphasis on evaluating their real-world desirability. Our review finds that self-help DMHIs are often perceived as less desirable and credible than in-person treatments, with lower usage rates and, perhaps accordingly, clinical trials testing self-help DMHIs suffering from widespread recruitment challenges. We highlight two fundamental challenges that may be interfering with the desirability of, and engagement in, self-help DMHIs: (1) difficulty competing with technology companies that have advantages in resources, marketing, and user experience design (but may not be delivering evidence-based interventions) and (2) difficulty retaining (vs initially attracting) users. We discuss a range of potential solutions, including highlighting self-help DMHIs in public mental health awareness campaigns; public education about evidence-based interventions that can guide consumers to appropriate self-help DMHI selection; increased financial and expert support to clinical researchers for marketing, design, and user experience in self-help DMHI development; increased involvement of stakeholders in the design of self-help DMHIs; and investing in more research on ways to improve retention (versus initial engagement). We suggest that, through these efforts, self-help DMHIs may fully realize their promise for reducing the global burden of mental illness.

Relations of body dissatisfaction with self-injurious thoughts and behaviours in clinical and non-clinical samples: a meta-analysis of studies published between 1995 and 2022

Body dissatisfaction is a global public health concern. Self-injurious thoughts and behaviours (SITB), including suicidal ideation, suicide attempts and non-suicidal self-injury (NSSI), have been documented as potentially significant correlates of body dissatisfaction. However, prior findings regarding associations between body dissatisfaction and SITB have been somewhat inconsistent. Therefore, this meta-analysis was conducted to determine the nature and strength of such associations in both clinical and non-clinical samples. A literature search identified 83 relevant articles and extracted 234 effect sizes. Using a three-level random-effects model, mean effect sizes (r values) for relationships between body dissatisfaction and suicidal ideation, suicide attempts, and NSSI in clinical samples were 0.29 (95% CI, 0.22-0.37), 0.16 (95% CI, 0.13-0.20) and 0.26 (95% CI, 0.19-0.34), respectively. In non-clinical samples, these values were 0.22 (95% CI, 0.16-0.28), 0.24 (95% CI, 0.17-0.30) and 0.22 (95% CI, 0.15-0.29), respectively. Several study features (e.g., participant age, geographic region and instrument validity) emerged as significant moderators. This meta-analysis provides robust support for body dissatisfaction as a significant correlate of SITB across clinical and non-clinical samples in addition to identifying study characteristics that contribute to effect size variability. Implications are discussed for SITB research, prevention and intervention.

'Who, When, How to Share': Pilot study of a new disclosure decision-making programme for autistic adults

LAY ABSTRACT

'Who, When, How to Share' is a new programme that aims to support autistic adults in making decisions around sharing their autistic identity with others. The programme involves working through a self-help guide independently over 3 weeks with optional peer support. We wanted to find out if autistic adults would join the programme and find it useful. Thirty-two autistic adults took part in the programme and 19 of them completed it. Most participants who completed the programme liked the programme and found it helpful, but some felt that they needed more time and support to complete it. They suggested that the programme would be more accessible if it was more interactive, such as including videos and other ways to gain feedback on their progress. Surveys filled in by participants before and after the programme suggested that they became more confident and less stressed about sharing their autistic identity with others, but some felt they still needed to build more confidence in order to handle negative attitudes from others. More work is needed to improve and test the programme further.

Motivational Variables as Moderating Effects of a Web-Based Mental Health Program for University Students: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Self-guided web-based interventions have the potential of addressing help-seeking barriers and symptoms common among university students, such as depression and anxiety. Unfortunately, self-guided interventions are also associated with less adherence, implicating motivation as a potential moderator for adherence and improvement for such interventions. Previous studies examining motivation as a moderator or predictor of improvement on web-based interventions have defined and measured motivation variably, producing conflicting results.

OBJECTIVE

This secondary analysis of data from a randomized controlled trial aimed to examine constructs of motivation as moderators of improvement for a self-guided 8-week web-based intervention in university students (N=1607).

METHODS

Tested moderators included internal motivation, external motivation, and confidence in treatment derived from the Treatment Motivation Questionnaire. The primary outcome was an improvement in depression and anxiety measured by the Depression Anxiety Stress Scale-21.

RESULTS

Piecewise linear mixed effects models showed that internal motivation significantly moderated symptom change for the intervention group (t1504=-2.94; P=.003) at average and high (+1 SD) motivation levels (t1507=-2.28; P=.02 and t1507=-4.05; P<.001, respectively). Significant results remained even after controlling for baseline severity. The results showed that confidence in treatment did not significantly moderate symptom change for the intervention group (t1504=1.44; P=.15). In this sample, only internal motivation was positively correlated with service initiation, intervention adherence, and intervention satisfaction.

CONCLUSIONS

The combination of a web-based intervention and high or moderate internal motivation resulted in greater improvement in the total Depression Anxiety Stress Scale-21 score. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. The results suggest that the combination of a web-based intervention and high or moderate internal motivation results in greater improvement. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. To better understand the moderating role of internal motivation, future research is encouraged to replicate these findings in diverse samples as well as to examine related constructs such as baseline severity and adherence. Understanding these characteristics informs treatment strategies to maximize adherence and improvement when developing web-based interventions as well as allows services to be targeted to individuals likely to benefit from such interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/study/NCT04361045.

Enhancing self-esteem in adults with body dysmorphic symptoms: experimental testing and initial evaluation of a brief internet-based training

BACKGROUND

Low self-esteem is an important factor associated with body dysmorphic concerns. In treatment, self-esteem cannot always be adequately addressed. Internet-based interventions offer a low-threshold and cost-efficient possibility for treating body dysmorphic disorder (BDD).

AIMS

For this reason, we conducted two studies to explore the effectiveness of an internet-based intervention targeting improving self-esteem in adults with BDD symptoms.

METHOD

The first study investigated the differential effects of a 1-week self-esteem training compared with a 1-week attention-focus training. Two hundred twenty adults with elevated body dysmorphic symptoms were randomly assigned to one of the two trainings. Our second study (n = 58 adults with body dysmorphic symptoms) evaluated an extended 2-week stand-alone self-esteem training.

RESULTS

In the first study, self-esteem in different domains (appearance, performance and social), self-focused attention, and BDD symptom severity improved in both groups. Other-focused attention only increased in the attention training group. Participants' overall adherence was high. In the second study we observed significant improvements in self-esteem, BDD symptom severity, and other secondary outcomes, with additional improvements in most outcomes in the second week. Adherence was again high.

CONCLUSIONS

Together, these findings show that a brief internet-based intervention may be a highly accepted and effective way of improving self-esteem in people suffering from BDD symptoms.

Understanding and optimising gratitude interventions: the right methods for the right people at the right time

OBJECTIVE

Gratitude has consistently been associated with various beneficial health-related outcomes, including subjective wellbeing, positive mental health, and positive physical health. In light of such effects, positive psychology researchers and practitioners have often implemented gratitude interventions in an attempt to build individuals' orientations toward appreciation and thankfulness. Recent meta-analyses and reviews have revealed, however, that these interventions often have mixed effects on gratitude or other health outcomes. With this issue in mind, we aimed to identify (a) contextual considerations that may impact the effectiveness of these approaches, and (b) recommendations for the optimisation of gratitude interventions.

METHODS AND MEASURES

Seventeen mental health professionals or experienced health psychology researchers engaged in semi-structured interviews to address the research questions.

RESULTS

Thematic analysis of the data resulted in three contextual themes-cultural considerations, personal characteristics, and life experience-that were discussed as factors likely to influence intervention effectiveness. With respect to recommendations, participants highlighted the importance of encouraging deep engagement in gratitude tasks, consistent repetition of those tasks, and the value of interpersonal expressions of gratitude.

CONCLUSION

Discussion is centred on suggestions for future research on gratitude and on implications for the implementation of gratitude interventions.

The Effect of Fear of COVID-19 Infection and Anxiety on Loneliness: Moderated Mediation Effects of Gratitude

OBJECTIVE

This study was conducted to identify factors related to loneliness during the coronavirus disease-2019 (COVID-19) pandemic and focused on how the fear of COVID-19 infection affects loneliness and the conditional effect of gratitude as a moderator in the relationship among the fear of COVID-19, anxiety, and loneliness.

METHODS

For the analysis of this study, a survey was conducted among 1,500 individuals aged 19 to 69 years living in three metropolitan areas in South Korea. Questionnaires included sociodemographic data, psychological experience and stress associated with COVID-19, Generalized Anxiety Disorder Scale-7, UCLA Loneliness Scale-3, and Gratitude Questionnaire-6. An analysis was conducted by applying SPSS PROCESS macro models 4 and 7.

RESULTS

First, anxiety mediated the relationship between the fear of COVID-19 infection and loneliness. Second, the effect of the fear of COVID-19 infection on loneliness through anxiety was moderated by gratitude. The higher the gratitude, the more the fear of COVID-19 infection is buffered in the path to anxiety, and the lower the indirect effect on loneliness.

CONCLUSION

This suggests that in the context of the COVID-19 pandemic, interventions for psychological problems such as anxiety and loneliness can be carried out through gratitude, a significant protective variable.

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study

BACKGROUND

Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS).

OBJECTIVE

We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS.

METHODS

A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study.

RESULTS

The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms.

CONCLUSIONS

The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

The Catalyst Model of Change: Gratitude Interventions with Positive Long-Term Effects

How can gratitude interventions be designed to produce meaningful and enduring effects on people's well-being? To address this question, the author proposes the Catalyst Model of Change-this novel, practical, and empirically testable model posits five socially oriented behavioral pathways that channel the long-term effects of gratitude interventions as well as how to augment gratitude experiences in interventions to boost treatment effects and catalyze these behavioral pathways. Specifically, interventions that enhance the frequency, skills, intensity, temporal span, and variety of gratitude experiences are likely to catalyze the following post-intervention socially oriented behaviors: (a) social support-seeking behaviors, (b) prosocial behaviors, (c) relationship initiation and enhancement behaviors, (d) participation in mastery-oriented social activities, and (e) reduced maladaptive interpersonal behaviors, which, in turn, produce long-term psychological well-being. A unique feature of the Catalyst Model of Change is that gratitude experiences are broadly conceptualized to include not just gratitude emotions, cognitions, and disclosures, but also expressing, receiving, witnessing, and responding to interpersonal gratitude. To this end, gratitude interventions that provide multiple opportunities for social experiences of gratitude (e.g., members expressing gratitude to each other in a group) might offer the greatest promise for fostering durable, positive effects on people's psychological well-being.

Engaging Dispositional Forgiveness: A Structure for Consistent Forgiveness Praxis

Although forgiveness is hard work, it enables individuals who have gone through unfairness and harm outgrow the pain of resentment and hostility to a condition of wellness and health. Still, it is possible that authentic forgiveness, regardless of significant violations may, as a matter of choice occur when the injured have hitherto achieved proficiency with the forgiveness praxis by practicing consistently. This manuscript suggests a brief dispositional forgiveness praxis that permits individuals to achieve experience in forgiving trivial faults on a consistent basis. Even though other forgiveness practices are in existence, this praxis is distinctive in that it draws from a philosophically and scientifically firm appreciation of the forgiveness procedures and is supposed to build up ones' capacity to forgive in the circumstances of more difficult wounding and unfairness that may occur ahead. Individual persons engage in this praxis by meditating upon smaller instances of wrongdoing from their everyday life and wade through six steps, each informed by inquiry in forgiveness counseling and self-understanding; to move from anger to empathy. A case study is provided to demonstrate one personal experience in engaging in one of consistent forgiveness praxis in the repercussions of a small wrongdoing.

A Web-Based, Mindful, and Compassionate Parenting Training for Mothers Experiencing Parenting Stress: Results from a Pilot Randomized Controlled Trial of the Mindful Moment Program

Objectives

Mindful Moment is a self-guided, web-based, mindful, and compassionate parenting training for postpartum mothers who experience parenting stress. We aimed to assess Mindful Moment’s feasibility, acceptability, and usability, and to gather preliminary evidence of its effectiveness in reducing parenting stress and outcomes such as mindful parenting, self-compassion, depressive symptoms, anxious symptoms, dispositional mindfulness, mother’s perception of infant temperament, and mother-infant bonding.

Methods

This pilot randomized controlled trial (RCT) was a two-arm trial and followed the CONSORT 2010, CONSORT-EHEALTH, and CONSORT-SPI 2018 extension guidelines. A total of 292 Portuguese mothers were randomly assigned to the intervention group (n = 146) or to the waiting list control group (n = 146) and completed baseline (T1) and postintervention (T2) self-reported assessments.

Results

A total of 31 mothers (21.23%) completed the Mindful Moment intervention. Most mothers evaluated the program as good or excellent (90%), considered that Mindful Moment provided them the kind of help they expected or wanted (61%), were satisfied with the help provided by the program (74.6%), would recommend it to a friend in a similar situation (86.4%), and would use it again if needed (81.4%). Regarding the program’s preliminary effectiveness, mothers in the intervention group presented a greater decrease in parenting stress, a greater increase in dispositional mindfulness, and a greater decrease in their perception of the difficult temperament of their infants from T1 to T2.

Conclusions

This study provides preliminary evidence of the Mindful Moment’s effectiveness and suggests that it is a feasible and acceptable program for postpartum mothers experiencing parenting stress. Further research is needed to confirm these results in a larger RCT.

Trial Registration

ClinicalTrials.gov (NCT04892082).

Differential adherence to peer and nurse components of a supportive care package-The appeal of peer support may be related to women's health and psychological status

OBJECTIVE

Knowledge of factors associated with intervention non-adherence may provide insights into the clinical utility of non-pharmacologic interventions.

METHODS

This study compared complete and incomplete adherers to two separate components of a novel intervention package for women undergoing curative intent radiotherapy for gynaecological cancer on socio-demographic, clinical and pre-radiotherapy patient-reported outcomes data.

RESULTS

Adherence to the tailored specialist nurse consultations was satisfactory (71% participated in all available sessions, 19% participated in all but one). Adherence to the telephone peer support sessions was less satisfactory (47% participated in all available sessions, 24% participated in all but one session). Complete adherers to the peer sessions reported significantly lower levels of psychological distress and significantly higher levels of physical, emotional and functional wellbeing before radiotherapy. No other statistically significant differences were observed between complete and incomplete adherers to the nurse- or peer-led sessions.

CONCLUSION

Women's ability or motivation to engage with peer support may be influenced by their health and psychological status. Further, the extent of intervention non-adherence to the peer-led component may have compromised the assessment of its efficacy.

PRACTICE IMPLICATIONS

Peer support may be less acceptable or appropriate for women with more complex care needs. Such women may prefer specialised care from trained professionals.

A Brief Gratitude Writing Intervention Decreased Stress and Negative Affect During the COVID-19 Pandemic

Exploring ways to mitigate the stress of the COVID-19 pandemic is important for long-term health. Expressive and gratitude-focused writing are effective methods to help individuals process traumatic or stressful events. Gratitude-focused writing may yield additional benefits because it helps individuals appraise events positively. We hypothesized that an online gratitude writing intervention would yield greater benefits than an expressive writing intervention or control group. Participants were randomized to one of three groups and completed assessments one-week and one-month post-intervention. The gratitude writing group maintained gratitude levels and decreased stress and negative affect at one-month post-intervention. The expressive writing group decreased in gratitude and showed no changes in stress or negative affect at one-month post-intervention. The control group decreased in gratitude and negative affect and showed no changes in stress at one-month post-intervention. Gratitude writing may be a better resource for dealing with stress and negative affect than traditional expressive writing methods under extremely stressful situations with uncertain trajectories.

Efficacy of a Single-Session "Empowered Relief" Zoom-Delivered Group Intervention for Chronic Pain: Randomized Controlled Trial Conducted During the COVID-19 Pandemic

BACKGROUND

Cognitive behavioral therapy-pain is an evidence-based treatment for chronic pain that can have significant patient burden, including health care cost, travel, multiple sessions, and lack of access in remote areas.

OBJECTIVE

The study aims to pilot test the efficacy of a single-session videoconference-delivered empowered relief (ER) intervention compared to waitlist control (WLC) conditions among individuals with chronic pain. We hypothesized that ER would be superior to WLC in reducing pain catastrophizing, pain intensity, and other pain-related outcomes at 1-3 months posttreatment.

METHODS

We conducted a randomized controlled trial involving a web-based sample of adults (N=104) aged 18-80 years with self-reported chronic pain. Participants were randomized (1:1) to 1 of 2 unblinded study groups: ER (50/104, 48.1%) and WLC (54/104, 51.9%). Participants allocated to ER completed a Zoom-delivered class, and all participants completed follow-up surveys at 2 weeks and 1, 2, and 3 months posttreatment. All the study procedures were performed remotely and electronically. The primary outcome was pain catastrophizing 1-month posttreatment, with pain intensity, pain bothersomeness, and sleep disruption as secondary outcomes. We also report a more rigorous test of the durability of treatment effects at 3 months posttreatment. Data were collected from September 2020 to February 2021 and analyzed using intention-to-treat analysis. The analytic data set included participants (18/101, 17.8% clinic patients; 83/101, 82.1% community) who completed at least one study survey: ER (50/101, 49.5%) and WLC (51/104, 49%).

RESULTS

Participants (N=101) were 69.3% (70/101) female, with a mean age of 49.76 years (SD 13.90; range 24-78); 32.7% (33/101) had an undergraduate degree and self-reported chronic pain for 3 months. Participants reported high engagement (47/50, 94%), high satisfaction with ER (mean 8.26, SD 1.57; range 0-10), and high satisfaction with the Zoom platform (46/50, 92%). For the between-groups factor, ER was superior to WLC for all primary and secondary outcomes at 3 months posttreatment (highest P<.001), and between-groups Cohen d effect sizes ranged from 0.45 to 0.79, indicating that the superiority was of moderate to substantial clinical importance. At 3 months, clinically meaningful pain catastrophizing scale (PCS) reductions were found for ER but not for WLC (ER: PCS -8.72, 42.25% reduction; WLC: PCS -2.25, 11.13% reduction). ER resulted in significant improvements in pain intensity, sleep disturbance, and clinical improvements in pain bothersomeness.

CONCLUSIONS

Zoom-delivered ER had high participant satisfaction and very high engagement. Among adults with chronic pain, this single-session, Zoom-delivered, skills-based pain class resulted in clinically significant improvement across a range of pain-related outcomes that was sustained at 3 months. Web-based delivery of ER could allow greater accessibility of home-based pain treatment and could address the inconveniences and barriers faced by patients when attempting to receive in-person care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04546685; https://clinicaltrials.gov/ct2/show/NCT04546685.

Evaluating the impact of a brief Health at Every Size®-informed health promotion activity on body positivity and internalized weight-based oppression

Weight-based oppression, including negative attitudes about body weight, and harassment, stigma, and discrimination based on body weight, is a widespread phenomenon that leads to considerable distress and poor health and wellbeing outcomes. Conversely, body positivity is a multi-faceted concept that encompasses body acceptance, body appreciation, and body love, and adaptive approaches protective of health and wellbeing. The aim of this study was to evaluate the impact of a brief health promotion activity informed by Health at Every Size® and critical health promotion principles on body positivity and internalized weight-based oppression in female students at Qatar University. A quasi-experimental mixed methods pre-post evaluation design was used, with quantitative assessment of body positivity and internalized weight-based oppression before the activity, immediately afterwards, and 10 weeks later, and qualitative assessment at the 10-week follow up. Measures used were the Body Appreciation Scale 2, Modified Weight Bias Internalization Scale, Fat Attitudes Assessment Toolkit Size Acceptance and Self Reflection on Body Acceptance subscales, and an open-ended questionnaire. Body acceptance and appreciation increased significantly after the activity. Qualitative results suggest that these improvements were sustained at follow up. Brief Health at Every Size® informed health promotion activities show potential to improve health and wellbeing.

None the wiser: Year-long longitudinal study on effects of adversity on wisdom

Research on consequences of adversity appears inconclusive. Adversity can be detriment to mental health, promoting maladaptive patterns of thoughts. At the same time, posttraumatic growth studies suggest that overcoming major adversity facilitates growth in wisdom-related patterns of thoughts. We address this puzzle by examining how distinct types of adversity impact wisdom over time and how individual differences in self-distanced (rather than self-immersed) reflection on adversity relate to different wisdom trajectories. In a four-wave prospective year-long study, participants ( N = 499) recalled and reflected every three months on the most significant recent adverse event in their life. They reported how much they engaged in wise reasoning—intellectual humility, open-mindedness to diverse perspectives and change, search for compromises and resolution—as well as self-distancing during reflections. Independent raters identified seven distinct adversity types (e.g. social conflict, economic hardship, major trauma) in open-ended descriptions. Growth curve analyses revealed little evidence of positive change in wise-reasoning over the course of a year, and some evidence of negative change for health-related adversity. Although self-distancing was associated with stability in wisdom, self-immersing was associated with negative change in wisdom in reflections on social conflicts over time. We discuss implications these results have for adversity, change vs. resilience in character strengths, and self-distancing.

Effects of a gratitude intervention program on work engagement among Japanese workers: a protocol for a cluster randomized controlled trial

BACKGROUND

Work engagement is one of the most important outcomes for both employees and employers. Although the findings to date, integrated 40 intervention studies aiming to improve work engagement, consistent results have not yet been produced, suggesting the importance of further intervention studies. This study aims to investigate the effects of gratitude intervention programs focused on two important work engagement factors among Japanese workers: personal and job resources.

METHODS

This study will be a two-arm, parallel-group cluster (organization) randomized control trial. Japanese organizations and nested employees will be recruited through the first author's acquaintances using snowball sampling. Organizations that meet the inclusion criteria will be randomly allocated to intervention or control groups in a 1:1 ratio within the company unit. The intervention groups will be provided with a 1-month long gratitude intervention program, which aims to promote reciprocal gratitude exchanges within the same organization. The program consists of psychoeducation, gratitude lists, and behavioral gratitude expression. The control groups will not receive any intervention. The primary outcome will be work engagement measured by the Japanese version of the Utrecht Work Engagement Scale at baseline and after 1 (immediate post-survey), 3, and 6 months. Multilevel latent growth modeling will be conducted to examine the effectiveness of the intervention program.

DISCUSSION

This study will be the first cluster randomized controlled trial applied to the investigation of gratitude intervention aimed at improving work engagement among Japanese workers; to promote reciprocal gratitude exchanges within a given organization; and to include both gratitude lists and behavioral gratitude expression. Gratitude interventions have several strengths in terms of implementation: the objectives of the exercises are easy to understand and implement; it does not require much time or expense; they tend to have lower dropout rates; and they do not require experts in psychology. Although implementation difficulties have been common in previous interventions targeting work engagement, gratitude intervention may be suitable even for workers who have limited time to devote to the tasks.

TRIAL REGISTRATION

This study was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR, ID=UMIN000042546): https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000048566 on November 25, 2020.

An 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality Program for Chronic Low Back Pain: Double-Blind, Randomized, Placebo-Controlled Trial Conducted During COVID-19

BACKGROUND

Chronic low back pain is the most prevalent chronic pain condition worldwide and access to behavioral pain treatment is limited. Virtual reality (VR) is an immersive technology that may provide effective behavioral therapeutics for chronic pain.

OBJECTIVE

We aimed to conduct a double-blind, parallel-arm, single-cohort, remote, randomized placebo-controlled trial for a self-administered behavioral skills-based VR program in community-based individuals with self-reported chronic low back pain during the COVID-19 pandemic.

METHODS

A national online convenience sample of individuals with self-reported nonmalignant low back pain with duration of 6 months or more and with average pain intensity of 4 or more/10 was enrolled and randomized 1:1 to 1 of 2 daily (56-day) VR programs: (1) EaseVRx (immersive pain relief skills VR program); or (2) Sham VR (2D nature content delivered in a VR headset). Objective device use data and self-reported data were collected. The primary outcomes were the between-group effect of EaseVRx versus Sham VR across time points, and the between-within interaction effect representing the change in average pain intensity and pain-related interference with activity, stress, mood, and sleep over time (baseline to end-of-treatment at day 56). Secondary outcomes were global impression of change and change in physical function, sleep disturbance, pain self-efficacy, pain catastrophizing, pain acceptance, pain medication use, and user satisfaction. Analytic methods included intention-to-treat and a mixed-model framework.

RESULTS

The study sample was 179 adults (female: 76.5%, 137/179; Caucasian: 90.5%, 162/179; at least some college education: 91.1%, 163/179; mean age: 51.5 years [SD 13.1]; average pain intensity: 5/10 [SD 1.2]; back pain duration ≥5 years: 67%, 120/179). No group differences were found for any baseline variable or treatment engagement. User satisfaction ratings were higher for EaseVRx versus Sham VR (P<.001). For the between-groups factor, EaseVRx was superior to Sham VR for all primary outcomes (highest P value=.009), and between-groups Cohen d effect sizes ranged from 0.40 to 0.49, indicating superiority was moderately clinically meaningful. For EaseVRx, large pre-post effect sizes ranged from 1.17 to 1.3 and met moderate to substantial clinical importance for reduced pain intensity and pain-related interference with activity, mood, and stress. Between-group comparisons for Physical Function and Sleep Disturbance showed superiority for the EaseVRx group versus the Sham VR group (P=.022 and .013, respectively). Pain catastrophizing, pain self-efficacy, pain acceptance, prescription opioid use (morphine milligram equivalent) did not reach statistical significance for either group. Use of over-the-counter analgesic use was reduced for EaseVRx (P<.01) but not for Sham VR.

CONCLUSIONS

EaseVRx had high user satisfaction and superior and clinically meaningful symptom reduction for average pain intensity and pain-related interference with activity, mood, and stress compared to sham VR. Additional research is needed to determine durability of treatment effects and to characterize mechanisms of treatment effects. Home-based VR may expand access to effective and on-demand nonpharmacologic treatment for chronic low back pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/25291.

Training for Wisdom: The Distanced-Self-Reflection Diary Method

How can people wisely navigate social conflict? Two preregistered longitudinal experiments (Study 1: Canadian adults; Study 2: American and Canadian adults; total N = 555) tested whether encouraging distanced (i.e., third-person) self-reflection would help promote wisdom. Both experiments measured wise reasoning (i.e., intellectual humility, open-mindedness about how situations could unfold, consideration of and attempts to integrate diverse viewpoints) about challenging interpersonal events. In a month-long experiment (Study 1), participants used either a third- or first-person perspective in diary reflections on each day's most significant experience. Compared with preintervention assessments, assessments made after the intervention revealed that participants reflecting in the third person showed a significant increase in wise reasoning about interpersonal challenges. These effects were statistically accounted for by shifts in diary-based reflections toward a broader self-focus. A week-long experiment (Study 2) replicated the third-person self-reflection effect on wise reasoning (vs. first-person and no-pronoun control conditions). These findings suggest an efficient and evidence-based method for fostering wise reasoning.

The Good Enough Parenting early intervention schema therapy based program: Participant experience

Background and objectives

Schema therapy (ST) has become a mainstream therapy for the treatment of psychopathology and has been validated through a series of large scale, international randomized control trials. Among other things, schema therapy emphasizes the meeting of core emotional needs in children by primary caregivers as these unmet needs continue to adversely affect their lives into adulthood. An early intervention parenting program has been developed to help parents meet these core emotional needs in order to prevent the development of psychopathology in the first place. The program, Good Enough Parenting, is equally focused on reducing problems and strengthening parenting practices, regardless of where the child is on the “disordered to well-being continuum”. This study aims to explore “patient experience” by users of this program. Best clinical research guidelines advocate that participants should be used as collaborators rather than pure recipients; this process should predate large scale trials.

Design

An exploratory qualitative study with 55 parent-participants of Good Enough Parenting was conducted.

Methods

One-to-one interviews were conducted with participants, using critical incident technique and guided by semi-structured interview schedule, to explore their experiences with the program. Transcripts were then analyzed using thematic analysis.

Results

Coding showed a high degree of inter-rater reliability (kappa value of 0.78). The themes that emerged were Cultivating Awareness of Parents’ Own Schemas, Cultivating Intentionality, Working through Developmental Issues, Responses to Challenges at Home, Performing Multiple Roles, and the Learning Process. Participants overwhelmingly reported satisfaction within these key themes.

Conclusions

The results support the development of the program and the choice of “participant reported outcome measures” for use in subsequent randomized controlled trials.

Factors associated with adherence to a web-based alcohol intervention among college students

Abstract This study aimed to evaluate the association between student characteristics and recruitment strategies in the adherence of college students to a web-based alcohol intervention. Participants were 46,329 Brazilian students aged from 18 to 30, who consumed alcohol during the past three months. Three recruitment strategies were implemented: open invitations, and personally-addressed invitations with or without non-monetary incentives. We evaluated the educational, sociodemographic, motivational, and alcohol consumption effects on adherence using logistic regression models. Women (aOR = 1.09 [1.04; 1.14]), students with higher income (aOR = 1.32 [1.21; 1.45]), and more motivated students (aOR = 1.04 [1.03; 1.05]) were more adherent to the intervention, as well as those reporting binge drinking (aOR = 1.26 [1.19; 1.33]) and alcohol hazardous use (aOR = 1.11 [1.05; 1.18]). The use of incentives was the main factor associated with adherence (aOR = 3.69 [2.46; 5.55]). Our results may help the development of future web-based interventions related to alcohol use.

Developing a Process for the Analysis of User Journeys and the Prediction of Dropout in Digital Health Interventions: Machine Learning Approach

Background

User dropout is a widespread concern in the delivery and evaluation of digital (ie, web and mobile apps) health interventions. Researchers have yet to fully realize the potential of the large amount of data generated by these technology-based programs. Of particular interest is the ability to predict who will drop out of an intervention. This may be possible through the analysis of user journey data—self-reported as well as system-generated data—produced by the path (or journey) an individual takes to navigate through a digital health intervention.

Objective

The purpose of this study is to provide a step-by-step process for the analysis of user journey data and eventually to predict dropout in the context of digital health interventions. The process is applied to data from an internet-based intervention for insomnia as a way to illustrate its use. The completion of the program is contingent upon completing 7 sequential cores, which include an initial tutorial core. Dropout is defined as not completing the seventh core.

Methods

Steps of user journey analysis, including data transformation, feature engineering, and statistical model analysis and evaluation, are presented. Dropouts were predicted based on data from 151 participants from a fully automated web-based program (Sleep Healthy Using the Internet) that delivers cognitive behavioral therapy for insomnia. Logistic regression with L1 and L2 regularization, support vector machines, and boosted decision trees were used and evaluated based on their predictive performance. Relevant features from the data are reported that predict user dropout.

Results

Accuracy of predicting dropout (area under the curve [AUC] values) varied depending on the program core and the machine learning technique. After model evaluation, boosted decision trees achieved AUC values ranging between 0.6 and 0.9. Additional handcrafted features, including time to complete certain steps of the intervention, time to get out of bed, and days since the last interaction with the system, contributed to the prediction performance.

Conclusions

The results support the feasibility and potential of analyzing user journey data to predict dropout. Theory-driven handcrafted features increased the prediction performance. The ability to predict dropout at an individual level could be used to enhance decision making for researchers and clinicians as well as inform dynamic intervention regimens.

Effective Gamification of the Stop-Signal Task: Two Controlled Laboratory Experiments

Background

A lack of ability to inhibit prepotent responses, or more generally a lack of impulse control, is associated with several disorders such as attention-deficit/hyperactivity disorder and schizophrenia as well as general damage to the prefrontal cortex. A stop-signal task (SST) is a reliable and established measure of response inhibition. However, using the SST as an objective assessment in diagnostic or research-focused settings places significant stress on participants as the task itself requires concentration and cognitive effort and is not particularly engaging. This can lead to decreased motivation to follow task instructions and poor data quality, which can affect assessment efficacy and might increase drop-out rates. Gamification—the application of game-based elements in nongame settings—has shown to improve engaged attention to a cognitive task, thus increasing participant motivation and data quality.

Objective

This study aims to design a gamified SST that improves participants’ engagement and validate this gamified SST against a standard SST.

Methods

We described the design of our gamified SST and reported on 2 separate studies that aim to validate the gamified SST relative to a standard SST. In study 1, a within-subject design was used to compare the performance of the SST and a stop-signal game (SSG). In study 2, we added eye tracking to the procedure to determine if overt attention was affected and aimed to replicate the findings from study 1 in a between-subjects design. Furthermore, in both studies, flow and motivational experiences were measured.

Results

In contrast, the behavioral performance was comparable between the tasks (P<.87; BF01=2.87), and the experience of flow and intrinsic motivation were rated higher in the SSG group, although this difference was not significant.

Conclusions

Overall, our findings provide evidence that the gamification of SST is possible and that the SSG is enjoyed more. Thus, when participant engagement is critical, we recommend using the SSG instead of the SST.

Journaling for self-care and coping in mothers of troubled children in the community

AIM

This mixed method research explored the benefits of a six-week diary writing intervention, and the coping strategies utilized in a sample of affected mothers who have teenagers or adult children with emotional and/or behavioral issues.

METHODS

Participants were assigned to write either a best possible self or a gratitude journal, and asked to make entries at least three times per week for six weeks. A snowball sample of 34 mothers completed the six-week journal and post-test.

RESULTS

The findings of paired t-tests indicated statistically significant increases in optimism and gratitude levels after completing the writing intervention. The mothers commonly used coping methods for parental distress were emotion-and meaning-focused coping. The three themes of journal writing experience were positive thinking, emotional well-being, and mental health self-care.

CONCLUSION

The current study suggests that implementing a positive writing intervention is a practical means of promoting psychological well-being as a self-care strategy for this population.

Gratitude and Adaptive Coping Among Chinese Singaporeans During the Beginning of the COVID-19 Pandemic

We report results of a cross-sectional survey conducted during March-April 2020 which marked the start and escalation of the COVID-19 crisis in Singapore. Our purpose was to examine whether reported feelings of gratitude among Chinese Singaporeans (N = 371; 124 males, 247 females; M _age = 22.54, SD _age = 3.63, age range: 18-53 years) could be linked to adaptive responses to the pandemic. The results revealed that gratitude was associated with stronger endorsement of virus-prevention measures (β = 0.25, p = 0.001) that are necessary for protecting the physical health of oneself and others but disruptive to daily lives. Gratitude was also positively related to the tendency to perceive meaningful benefits in the crisis (β = 0.25, p = 0.002). Importantly, demonstrating the uniqueness and robustness of gratitude as a predictor of positive coping in response to the pandemic, these relationships remained significant when controlling for other protective psychological factors (resilience and optimism), emotions, and key demographic variables. Among the emotions measured, gratitude was also reported the most strongly. The findings support theoretical models that gratitude facilitates prosocial inclinations and openness to different ways to support the well-being of others and suggest that in a collectivistic culture, gratitude could be a key resource enabling adaptation to a crisis.

Between-Individual Differences in Baseline Well-Being and Emotion Regulation Strategy Use Moderate the Effect of a Self-Help Cognitive-Behavioral Intervention for Typical Adults

BACKGROUND

Self-help interventions intended to help nonclinical individuals regulate their emotions can have important social benefits (i.e. mental disorder prevention, well-being promotion). However, their mean effect size on well-being is generally low, possibly because there are considerable between-individual differences in the response to these interventions. The present study examined whether individuals' baseline levels of emotional well-being and engagement in emotion regulation strategies moderate the effects on these same variables in a 4-week self-help cognitive-behavioral intervention intended for typical adults.

METHODS

Data were collected from 158 nonclinical French adults (n = 95 for the control group, n = 63 for the cognitive-behavioral group) using experience sampling. Emotional well-being was assessed, as well as the engagement in three emotion regulation strategies (i.e. cognitive reappraisal, problem solving, and appreciation).

RESULTS

As expected, the post-test scores on some variables were significantly predicted by the interactions between the intervention and the pre-test scores on these same variables. In particular, it was the participants with the most negative baseline levels (i.e. low emotional well-being, low engagement in appreciation) who benefitted most from the intervention.

CONCLUSIONS

Results are discussed in the light of current knowledge on between-individual differences in how individuals respond to interventions.

Accelerating Adolescent Vocabulary Growth: Development of an Individualized, Web-Based, Vocabulary Instruction Program

Purpose Improving vocabulary knowledge is important for many adolescents, but there are few evidence-based vocabulary instruction programs available for high school students. The purpose of this article is to describe the iterative development of the DictionarySquared research platform, a web-based vocabulary program that provides individualized vocabulary instruction, and to report the results of 2 pilot studies examining the feasibility of implementation and potential effectiveness with high school students. Method We describe our theory of change and 5 phases of iterative development. In Phases 1 and 2, we evaluated the initial implementation of DictionarySquared and revised the instructional materials. In Phase 3, we conducted a feasibility study involving 169 high school students who used the program for 4 weeks. Student usage data and feedback from teachers were used to guide program revisions in Phase 4. In Phase 5, we examined potential effectiveness for 264 high school students who were assigned to use the program for 1 semester. Results Results of the Phase 3 study indicated that implementation of the program was feasible, although usage was below assigned levels. Results of the Phase 5 study indicated that the duration of active program usage significantly predicted posttest vocabulary scores on the proximal assessment after controlling for pretest standardized vocabulary scores. Analyses using propensity score matching revealed positive, but nonsignificant, gains on standardized assessments between pre- and posttests. Conclusion Together, the results of early-stage pilot studies are promising and suggest that a more rigorous test of efficacy is warranted. Successful implementation of the DictionarySquared research program, as well as lessons learned from the program development process, will expand the range of evidence-based treatment options that clinicians and educators can use to improve adolescent vocabulary and reading comprehension skills. Supplemental Material https://doi.org/10.23641/asha.9765161.

The MARIGOLD study: Feasibility and enhancement of an online intervention to improve emotion regulation in people with elevated depressive symptoms

BACKGROUND

This manuscript describes the first two phases of pilot testing MARIGOLD, an online self-guided positive emotion skills intervention for adults with elevated depressive symptoms, along with enhancements to overcome retention and adherence problems reported in previous research.

METHODS

Adults with elevated depressive symptoms were recruited online and assessed at baseline, post-intervention, 1- and 3-month follow-up. Phase 1 participants (n = 58) were randomized to MARIGOLD, daily emotion reporting, or waitlist. Phase 2 participants (n = 79) were randomized to MARIGOLD plus one enhancement: online discussion board (ODB), virtual badges (VB), or facilitator contact (FC). Post-intervention interviews assessed acceptability. Intention-to-treat analyses examined retention, adherence, and preliminary efficacy.

RESULTS

In both phases, retention and adherence did not differ between groups. MARIGOLD skills were highly acceptable, but qualitative results indicate web-based features (e.g., log-in, ODB, VB) require refinement prior to larger testing. Neither phase demonstrated between-group differences in preliminary efficacy. In Phase 1 within-group analyses, MARIGOLD and emotion reporting control demonstrated a similar pattern of findings (stable depressive symptoms, increased positive emotion, decreased negative emotion and stress), whereas the waitlist group significantly increased in depressive mood. Most Phase 2 within-group analyses demonstrated the expected pattern of results (i.e., decreases in PHQ-8 and negative emotion, increases in positive emotion). However, CES-D scores were stable in FC; perceived stress was stable in FC and ODB.

LIMITATIONS

This pilot study is not powered to evaluate efficacy.

CONCLUSION

Positive emotion skills, plus enhancements for web-based, self-guided delivery, warrant additional study in people with elevated depressive symptoms.

Efficacy of an internet and app-based gratitude intervention in reducing repetitive negative thinking and mechanisms of change in the intervention's effect on anxiety and depression: Results from a randomized controlled trial

Repetitive negative thinking (RNT) has been identified as a transdiagnostic process that is involved in various forms of psychopathology, including anxiety and depression. This randomized controlled trial compared a 5-week internet and app-based gratitude intervention (intervention group; IG) with adherence-focused guidance against a wait list control group (WLG) in reducing RNT in a sample with elevated RNT.

METHOD

A total of 260 individuals were randomized to either the IG or the WLG. Data were collected at baseline (T1), within one week post intervention (T2), and at three (3-MFU) and six-months of follow-up (6-MFU; for IG only). The primary outcome was RNT. Secondary outcomes included other mental health outcomes and resilience factors.

RESULTS

Participants of the IG reported significantly less RNT at T2 (d = 0.61) and 3-MFU (d = 0.75) as compared to WLG. Improvements were sustained until 6-MFU. Significant, small to moderate effect sizes were identified for most secondary outcomes at T2 and 3-MFU. Furthermore, results of mediation analyses revealed that the gratitude intervention exerts its effect on anxiety and depression by reducing the risk factor of RNT, while the mediating role of resilience was less clear.

CONCLUSIONS

The gratitude intervention investigated in this study was found to be effective in reducing RNT. Gratitude interventions might affect mental health by two parallel pathways: increasing resources and reducing risk factors.

REFERENCE NUMBER ETHICS COMMITTEE OF THE UNIVERSITY OF LUENEBURG

EB 201701-03-Lehr.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS00011862. The trial protocol can be assessed at: https://www.drks.de/.

Interrelations between participant and intervention characteristics, process variables and outcomes in online interventions: A protocol for overarching analyses within and across seven clinical trials in ICare

BACKGROUND

It is well known that web-based interventions can be effective treatments for various conditions. Less is known about predictors, moderators, and mediators of outcome and especially interrelations between participant and interventions characteristics, process variables and outcomes in online interventions. Clinical trials often lack statistical power to detect variables that affect intervention effects and their interrelations. Within ICare, we can investigate the interrelation of potential predictor and process variables in a large sample.

METHOD

The ICare consortium postulated a model of interrelations between participant and intervention characteristics, process variables and outcomes in online interventions. We will assess general and disorder-specific interrelations between characteristics of the intervention, characteristics of the participants, adherence, working alliance, early response, and intervention outcomes in a sample of over 7500 participants from seven clinical trials evaluating 15 online interventions addressing a range of mental health conditions and disorders, using an individual participant data meta-analyses approach.

DISCUSSION/CONCLUSION

Existing research tends to support the efficacy of online mental health interventions, but the knowledge base regarding factors that affect intervention effects needs to be expanded. The overarching analyses using data from the ICare intervention trials will add considerably to the evidence.

Internet-based aftercare for women with bulimia nervosa following inpatient treatment: The role of adherence

Facing poor long-term outcome and high relapse rates in the treatment of bulimia nervosa, we developed an Internet-based aftercare program for women with severe and chronic bulimia nervosa following inpatient treatment based on previous experiences with self-directed targeted prevention and early intervention programs delivered online. The aim of the present study was to examine adherence to the program in detail, to explore potential variables that predict adherence and to analyze whether adherence affects outcomes. We analyzed data from 126 women in the intervention group of a randomized controlled trial. 107 women (85%) logged on to the program platform at least once. These women opened on average 42.8% (SD = 31.9%) of all assigned program pages. Adherence declined during the course of the intervention. Adherence was not associated with the number of outpatient treatment sessions received during the intervention period. Adherence was not related to overall illness severity or duration at baseline. However, excessive exercise at hospital discharge (which may be a sign of insufficient motivation to change eating disorder related behaviors) seems to play some small role in adherence. Adherence did not affect intervention outcomes. Based on our findings, we would like to advocate further research on online aftercare interventions for women with severe and chronic bulimia nervosa.

Audio and Computer Cognitive Behavioral Therapy for Depressive Symptoms in Older Adults: A Pilot Randomized Controlled Trial

The purpose of this study was to develop and explore the feasibility of audio-based (ACBT) and computer-based (CCBT) cognitive behavioral therapies for older adults with depressive symptoms. The audio program consisted of 8 compact discs and a workbook while the computer program consisted of 11 modules of similar duration provided on a tablet PC. Both interventions consisted of the following topics: identifying and changing unhelpful thoughts, addressing feelings, relaxation, engaging in pleasant events, assertiveness, and problem-solving. Fifty-one older adults were recruited from medical settings and rural communities. Participants were randomly assigned to immediate treatment (ACBT or CCBT) or delayed treatment control condition. Analyses were conducted to examine change on interviewer-based and self-reported depression. A significant interaction effect between time and condition was found on the interviewer-based depression scale. This suggests that both types of treatments decreased depressive symptoms over time when compared to a delayed treatment control. Computer-based and audio-based cognitive behavioral treatments may be valuable low-cost modalities to deliver psychotherapy to older adults with depressive symptoms.

Harnessing centred identity transformation to reduce executive function burden for maintenance of health behaviour change: the Maintain IT model

The inability to produce sustainable lifestyle modifications (e.g., physical activity, healthy diet) remains a major barrier to reducing morbidity and mortality from prevalent, preventable conditions. The objective of this paper is to present a model that builds on and extends foundational theory and research to suggest novel approaches that may help to produce lasting behaviour change. The model aims to integrate factors not typically examined together in order to elucidate potential processes underlying a shift from behaviour initiation to long-term maintenance. The central premise of the Maintain IT model builds on approaches demonstrating that in-tact executive function (EF) is critical for health behaviour initiation, for more complex behaviours beyond initiation, and in unsupportive environments and circumstances, but successful recruitment of EF is effortful and prone to error. Enduring changes are more likely if the underlying cognitive processes can become less effortful (non-conscious, automatic). The Maintain IT model posits that a centred identity transformation is one path leading to less effortful processing and facilitating successful recruitment of EF when necessary over the long term, increasing the sustainability of health behaviour change. A conceptual overview of the literature supporting the utility of this integrative model, future directions, and anticipated challenges are presented.

A Self-Paced, Web-Based, Positive Emotion Skills Intervention for Reducing Symptoms of Depression: Protocol for Development and Pilot Testing of MARIGOLD

BACKGROUND

Living with elevated symptoms of depression can have debilitating consequences for an individual's psychosocial and physical functioning, quality of life, and health care utilization. A growing body of evidence demonstrates that skills for increasing positive emotion can be helpful to individuals with depression. Although Web-based interventions to reduce negative emotion in individuals with depression are available, these interventions frequently suffer from poor retention and adherence and do not capitalize on the potential benefits of increasing positive emotion.

OBJECTIVE

The aim of this study was to develop and test a Web-based positive emotion skills intervention tailored for individuals living with elevated depressive symptoms, as well as to develop and test enhancement strategies for increasing retention and adherence to that intervention.

METHODS

This study protocol describes the development and testing for Mobile Affect Regulation Intervention with the Goal of Lowering Depression (MARIGOLD), a Web-based positive emotion skills intervention, adapted for individuals with elevated depressive symptomatology. The intervention development is taking place in three phases. In phase 1, we are tailoring an existing positive emotion skills intervention for individuals with elevated symptoms of depression and are pilot testing the tailored version of the intervention in a randomized controlled trial with two control conditions (N=60). In phase 2, we are developing and testing three enhancements aimed at boosting retention and adherence to the Web-based intervention (N=75): facilitator contact, an online discussion board, and virtual badges. In phase 3, we are conducting a multifactorial, nine-arm pilot trial (N=600) to systematically test these enhancement strategies, individually and in combination. The primary outcome is depressive symptom severity. Secondary outcomes include positive and negative emotion, psychological well-being, and coping resources.

RESULTS

The project was funded in August 2014, and data collection was completed in May 2018. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2018.

CONCLUSIONS

Findings from this investigation will enable us to develop an optimal package of intervention content and enhancement strategies for individuals with elevated symptoms of depression. If this intervention proves to be effective, it will provide a cost-effective, anonymous, appealing, and flexible approach for reducing symptoms of depression and improving psychological adjustment through increasing positive emotion.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01964820 (Phase 1); https://clinicaltrials.gov/ct2/show/NCT01964820 (Archived by WebCite at http://www.webcitation.org/6zpmKBcyX). ClinicalTrials.gov NCT02861755 (Phase 2); https://clinicaltrials.gov/ct2/show/NCT02861755 (Archived by WebCite at http://www.webcitation.org/6zpmLmy8k).

REGISTERED REPORT IDENTIFIER

RR1-10.2196/10494.

An attitude of gratitude: The effects of body-focused gratitude on weight bias internalization and body image

Internalized weight bias and body dissatisfaction are associated with a number of negative psychological and physical health outcomes. The current study examined the effectiveness of body-focused gratitude, through a short writing exercise, as a strategy to reduce internalized weight bias and improve body image. Young adults (M_age = 22.71, SD = 2.08, 51.2% female) were randomly assigned to either a body gratitude condition (n = 185) or a control condition (n = 184). Results indicated that participants in the gratitude condition reported significantly lower weight bias internalization and significantly more favorable appearance evaluation and greater body satisfaction when compared to the control condition. These effects were in the small range (ds = 0.27-0.33), and neither gender nor BMI moderated these effects. These findings provide preliminary support for body-focused gratitude writing exercises as an effective individual-level strategy for both reducing internalized weight bias and improving body image.

Development and exploration of the gratitude model of body appreciation in women

Although researchers and clinicians recognize the importance of positive body image for women's well-being, development of theoretical frameworks for understanding positive body image has not kept pace with research documenting its many benefits. The present study proposed and tested a comprehensive model linking gratitude, contingent self-worth, social comparison, body appreciation, and intuitive eating. Path analysis indicated that this model fit the data for a sample of college and online community women (N = 263). Gratitude was indirectly linked to body appreciation via lower investment in self-worth based on appearance and others' approval, and via lower engagement in eating and body comparison. Gratitude had a strong direct effect on body appreciation, and body appreciation accounted for a large portion (88%) of gratitude's relationship with intuitive eating. These results provide strong preliminary support for the model, revealing that gratitude, which can be improved via intervention, plays a key role in body appreciation.

Happy Despite Pain: A Randomized Controlled Trial of an 8-Week Internet-delivered Positive Psychology Intervention for Enhancing Well-being in Patients With Chronic Pain

Supplemental Digital Content is available in the text.

Objectives:

There is preliminary evidence for the efficacy of positive psychology interventions for pain management. The current study examined the effects of an internet-based positive psychology self-help program for patients with chronic musculoskeletal pain and compared it with an internet-based cognitive-behavioral program.

Materials and Methods:

A randomized controlled trial was carried out with 3 conditions: an internet-delivered positive psychology program, an internet-delivered cognitive-behavioral program and waitlist control. A total of 276 patients were randomized to 1 of the 3 conditions and posttreatment data were obtained from 206 patients. Primary outcomes were happiness, depression, and physical impairments at posttreatment and at 6-month follow-up. Intention-to-treat analyses were carried out using mixed regression analyses.

Results:

Both treatments led to significant increases in happiness and decreases in depression. Physical impairments did not significantly decrease compared with waitlist. Improvements in happiness and depression were maintained until 6-month follow-up. There were no overall differences in the efficacy of the 2 active interventions but effects seemed to be moderated by education. Patients with a higher level of education profited slightly more from the positive psychology intervention than from the cognitive-behavioral program.

Discussion:

The results suggest that an internet-based positive psychology and cognitive-behavioral self-help interventions for the management of chronic pain are clinically useful. Because the self-help exercises as used in the current program do not require therapist involvement, dissemination potential is large. Further studies should examine whether it can best be used as stand-alone or add-on treatment combined with established pain treatment programs.

A Self-Regulation-Based eHealth Intervention to Promote a Healthy Lifestyle: Investigating User and Website Characteristics Related to Attrition

BACKGROUND

eHealth interventions can reach large populations and are effective in increasing physical activity (PA) and fruit and vegetable intake. Nevertheless, the effects of eHealth interventions are overshadowed by high attrition rates. Examining more closely when users decide to leave the intervention can help eHealth developers to make informed decisions about which intervention components should be reshaped or simply removed. Investigating which users are more likely to quit an intervention can inform developers about whether and how their intervention should be adapted to specific subgroups of users.

OBJECTIVE

This study investigated the pattern of attrition in a Web-based intervention to increase PA, fruit, and vegetable intake. The first aim was to describe attrition rates according to different self-regulation components. A second aim was to investigate whether certain user characteristics are predictors for start session completion, returning to a follow-up session and intervention completion.

METHODS

The sample consisted of 549 adults who participated in an online intervention, based on self-regulation theory, to promote PA and fruit and vegetable intake, called "MyPlan 1.0." Using descriptive analysis, attrition was explored per self-regulation component (eg, action planning and coping planning). To identify which user characteristics predict completion, logistic regression analyses were conducted.

RESULTS

At the end of the intervention program, there was an attrition rate of 78.2% (330/422). Attrition rates were very similar for the different self-regulation components. However, attrition levels were higher for the fulfillment of questionnaires (eg, to generate tailored feedback) than for the more interactive components. The highest amount of attrition could be observed when people were asked to make their own action plan. There were no significant predictors for first session completion. Yet, two subgroups had a lower chance to complete the intervention, namely male users (OR: 2.24, 95% CI=1.23-4.08) and younger adults (OR: 1.02, 95% CI=1.00-1.04). Furthermore, younger adults were less likely to return to the website for the first follow-up after one week (OR: 1.03, 95% CI=1.01-1.04).

CONCLUSIONS

This study informs us that eHealth interventions should avoid the use of extensive questionnaires and that users should be provided with a rationale for several components (eg, making an action plan and completing questions). Furthermore, future interventions should focus first on motivating users for the behavior change before guiding them through action planning. Though, this study provides no evidence for removal of one of the self-regulation techniques based on attrition rates. Finally, strong efforts are needed to motivate male users and younger adults to complete eHealth interventions.

Comparison of a gratitude-based and cognitive restructuring intervention for body dissatisfaction and dysfunctional eating behavior in college women

Researchers have investigated the efficacy of a gratitude intervention for decreasing body dissatisfaction (BD) in an internet treatment-seeking sample and demonstrated it worked equally well to decrease BD as cognitive restructuring. We extend this research by testing the efficacy of a gratitude intervention on BD, along with common sequelae of BD: dysfunctional eating, negative mood, and depressive symptoms. Females were randomly assigned to Gratitude, Cognitive Restructuring, or Control conditions. Pre- to post-intervention period comparisons found the gratitude intervention to perform better than the other conditions at increasing body esteem, decreasing BD, reducing dysfunctional eating, and reducing depressive symptoms.

A qualitative exploration of barriers and facilitatorsto adherence to an online self-help intervention for cancer-related distress

OBJECTIVE

This study qualitatively explored barriers and facilitators of adherence to an online psychological intervention for cancer-related distress.

METHODS

Semi-structured interviews were conducted with 13 adults with cancer, randomised to receive either a 6-week intervention (n = 8) or attention control (n = 5) as part of a larger RCT. Transcripts were coded for themes and subthemes, and recruitment ceased when saturation of themes occurred.

RESULTS

Adherence overall was high: six participants completed all six modules, three completed five modules, two completed four modules, one completed one module, and one did not access the program. The total numbers of barriers (n = 19) and facilitators (n = 17) identified were equivalent and were categorised into five overarching themes: illness factors, psychological factors, personal factors, intervention factors and computer factors. However, the prevalence with which themes were discussed differed: illness factors (specifically cancer treatment side effects) were the main reported barrier to adherence; intervention factors (email reminders, program satisfaction, ease of use, program content) were the most common facilitators.

CONCLUSION

While some factors were cited as both facilitating and barring adherence, and therefore reflective of personal preferences and circumstances, a number of recommendations were derived regarding (i) the best timing for online interventions and (ii) the need for multi-platform programs.

Uptake and adherence to an online intervention for cancer-related distress: older age is not a barrier to adherence but may be a barrier to uptake

PURPOSE

While online interventions are increasingly explored as an alternative to therapist-based interventions for cancer-related distress, limitations to efficacy potentially include low uptake and adherence. Few predictors of uptake or adherence to online interventions have been consistently identified, particularly in individuals with cancer. This study examined rates and predictors of uptake and adherence to Finding My Way, a RCT of an online intervention versus an information-only online control for cancer-related distress.

METHODS

Participants were adults with cancer treated with curative intent. Adherence was assessed by login frequency, duration and activity level; analyses examined demographic, medical and psychological predictors of uptake and adherence.

RESULTS

The study enrolled 191 adults (aged 26-94 years) undergoing active treatment for cancer of any type. Uptake was highest for females and for individuals with ovarian (80%) and breast cancer (49.8%), and lowest for those with melanoma (26.5%). Adherence was predicted by older age and control-group allocation. Baseline distress levels did not predict adherence. High adherers to the full intervention had better emotion regulation and quality of life than low adherers.

CONCLUSIONS

Uptake of online intervention varies according to age, gender and cancer type. While uptake was higher amongst younger individuals, once enrolled, older individuals were more likely to adhere to online interventions for cancer-related distress.

Determinants of Perceived Stress in Individuals with Obesity: Exploring the Relationship of Potentially Obesity-Related Factors and Perceived Stress

OBJECTIVE

Associations of specific types of stress with increased food intake and subsequent weight gain have been demonstrated in animal models as well as in experimental and epidemiological studies on humans. This study explores the research question of to what extent potentially obesity-related factors determine perceived stress in individuals with obesity.

METHODS

N = 547 individuals with obesity participated in a cross-sectional study assessing perceived stress as the outcome variable and potential determinants of stress related to obesity. Based on the available evidence, a five factorial model of 'obesity-related obesogenic stressors' was hypothesized, including the dimensions, 'drive for thinness', 'impulse regulation', 'ineffectiveness', 'social insecurity', and 'body dissatisfaction'. The model was tested using multiple linear regression analyses.

RESULTS

The five factorial model of 'potentially obesity-related stressors' resulted in a total variance explanation of adjusted R² = 0.616 for males and adjusted R² = 0.595 for females for perceived stress. The relative variance contribution of the five included factors differed substantially for the two sexes.

CONCLUSION

The findings of this cross-sectional study support the hypothesized, potentially obesity-related factors: 'drive for thinness', 'impulse regulation', 'ineffectiveness', 'social insecurity', and 'body dissatisfaction' as relevant determinants of perceived stress in individuals with obesity.