Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden: a randomised, clinical, non-inferiority trial

A guide for self-help guides: best practice implementation

Guided self-help is an evidence-based intervention used globally. Self-help is a fundamental part of the stepped care model of mental health services that enables the efficient use of limited resources. Despite its importance, there is little information defining the role of the guide and the key competences required. In this context, the guide is defined as the person who facilitates and supports the use self-help materials. This article sets out the role of the guide in guided self-help. It considers practical issues such as the importance of engagement to motivate clients for early change, personalising the intervention, structuring sessions, how best to use routine outcome monitoring and supervision requirements. Key competences are proposed, including generic competences to build the relationship as well as specific competences such as being able to clearly convey the role of the guide to clients. Guides should be prepared for "self-help drift", a concept akin to therapist drift in more traditional therapies. Knowing how to identify mental health problems, use supervision and manage risk and comorbidity are all key requirements for guides. The paper concludes by calling for increased recognition and value of the role of the guide within mental health services.

A scoping review of therapist behaviors in guided digital mental health interventions

Guided digital mental health interventions are more effective than unguided interventions. While research often emphasizes the frequency and intensity of guidance, less attention has been paid to the behaviors enacted by the therapists supporting clients using these interventions. A scoping review of the literature was conducted to systematically examine the evidence on therapist behaviors (i.e., the actions and feedback provided by supporters to patients). Applying broad eligibility criteria, a systematic search was conducted in PubMed, PsycInfo, the Cochrane Library, and Embase from their inception to January 1st 2024. Sixteen studies met inclusion criteria and were included in the review. Following data extraction, a descriptive analysis and synthesis of the results was performed. Most studies (n = 12; 75 %) focused on therapist behaviors in the context of internet-delivered Cognitive Behavioral Therapy for anxiety and depression. While earlier studies primarily focused on identifying therapist behaviors, later studies shifted towards examining the associations between therapist behaviors and different outcomes, as well as deriving research and clinical applications for improving guided internet-delivered treatments. Identified gaps and recommendations for clinical practice, research, training, and treatment development are discussed.

Association between stress types and adolescent suicides: findings from the Korea Youth Risk Behavior Survey

Objective

This study aims to explore the association between types of stress and suicidal behaviors-ideation and attempts-among Korean adolescents in two distinct years: 2015 and 2020.

Methods

Data were acquired from the Korea Youth Risk Behavior Web-based Survey conducted in 2015 and 2020. Participants' desire for suicide was evaluated by asking questions about suicidal ideation and attempts, during the past year. Types of stress were divided into five categories: none, home, school, academic achievement, and appearance. Multiple logistic regression was used to investigate the association between variables of interest and dependent variables.

Results

Among the 77,363 adolescents included in this study, 8.8% male and 13.2% female participants had seriously thought about committing suicide, and the rate of male and female participants who tried committing suicide was 1.6% and 2.5%, respectively. While every type of stress was highly associated with suicidal ideation, family and home types of stress had the highest odds ratio (OR), that was statistically significant for both sexes (Male: OR 3.81, 95% Confidence Interval [CI] 2.81 to 5.15; Female: OR 3.64, 95% CI 2.42 to 5.50). Moreover, the OR increased in order of: appearance; academic achievement; school and friends; and family and home, compared to the group that perceived no stress. Suicidal attempts were statistically significant and higher in likelihood, only amongst the female group that experienced stress from family and home (OR 2.48, 95% CI 1.08 to 5.67). In comparison to year 2015, suicidal ideation and attempts decreased in year 2020, but participants experiencing stress from family and home had a higher tendency of attempting suicide, though not statistically significant, regardless of their sex (Male: OR 1.03, 95% CI 0.74 to 1.44; Female: OR 1.06, 95% CI 0.81 to 1.4).

Conclusion

Adolescents who experience stress from family and home, or school and friends, are more likely to think about suicide, or carry it out, as compared to those having different causes of stress.

"I didn't have to look her in the eyes"-participants' experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

Objective: To explore young people's perceptions of the relationship with the therapist in internet-based psychodynamic treatment for adolescent depression.Method: As a part of a randomized controlled trial, 18 adolescents aged 15-19 were interviewed after participating in treatment. Interviews followed a semi-structured interview schedule and were analyzed using thematic analysis.Results: The findings are reported around four main themes: "a meaningful and significant relationship with someone who cared", "a helping relationship with someone who guided and motivated me through therapy"; "a relationship made safer and more open by the fact that we didn't have to meet" and "a nonsignificant relationship with someone I didn't really know and who didn't know me".Conclusion: Even when contact is entirely text-based, it is possible to form a close and significant relationship with a therapist in internet-based psychodynamic treatment. Clinicians need to monitor the relationship and seek to repair ruptures when they emerge.Trial registration: ISRCTN.org identifier: ISRCTN16206254..

Time-lagged panel models in psychotherapy process and mechanisms of change research: Methodological challenges and advances

In recent years, there has been increasing interest in utilizing time-lagged panel models to study mechanisms of change in psychotherapy. These models offer valuable insights into the dynamic relationships between variables over time and offer stronger causal inference capabilities than cross-sectional analyses. Therefore, they are well-suited for modeling the intricate relationships between mechanisms of change and outcomes in psychotherapy studies, which are typically beyond experimental control. However, their complexity, coupled with the fact that detailed explanations are often embedded in dense statistical or econometric texts, poses challenges. This paper provides a background on cross-lagged panel models and delves deeper into explaining the issues of 1) dynamic panel bias, 2) long-run effects, and 3) testing whether different treatments work by different mechanisms. Using data from a psychotherapy study on treatment of adolescent depression, I demonstrate how these issues manifest in real data. In conclusion, I recommend using structural equation modeling to circumvent dynamic panel bias, reporting long-run effects to reveal the long-term impact of sustained therapeutic work on mechanisms of change, and carefully considering whether mediation, moderation, or a combination of both, best describes differential effects of mechanisms between treatments.

Associations of evening-type and insomnia symptoms with depressive symptoms among youths

BACKGROUND

Evening-type and insomnia symptoms are significantly related to each other and independently associated with depressive symptoms, yet few studies have examined the potential interaction between these two conditions. Therefore, we aimed to examine the associations of evening-type and insomnia symptoms with depressive symptoms among Chinese youths, with a specific focus on the joint effects of the two conditions on depressive symptoms.

METHODS

Participants aged between 12 and 25 were invited to participate in an online survey from December 15, 2022, to May 26, 2023. Multivariate logistic regression models and additive interaction models were used to examine the independent and joint effects of chronotypes and insomnia symptoms on depressive symptoms, respectively.

RESULTS

Of the 6145 eligible youths, the prevalence of evening-type and insomnia symptoms were 24.9 % and 29.6 %, respectively. Both evening-type (adjusted OR, [AdjOR]: 3.21, 95 % CI: 2.80-3.67) and insomnia symptoms (AdjOR: 10.53, 95 % CI: 9.14-12.12) were associated with an increased risk of depressive symptoms. In addition, the additive interaction models showed that there is an enhanced risk of depression related to interaction between evening-type and insomnia symptoms (relative excess risk due to interaction, [RERI]: 11.66, 95 % CI: 7.21-16.11).

CONCLUSIONS

The present study provided additional evidence demonstrating the presence of interaction between evening-type and insomnia symptoms, which can lead to a higher risk of depressive symptoms. Our findings argue the need for addressing both sleep and circadian factors in the management of depressive symptoms in young people.

Guided and unguided internet-delivered psychodynamic therapy for social anxiety disorder: A randomized controlled trial

Social Anxiety Disorder (SAD) is highly prevalent and debilitating disorder. Treatments exist but are not accessible and/or helpful for all patients, indicating a need for accessible treatment alternatives. The aim of the present trial was to evaluate internet-delivered psychodynamic therapy (IPDT) with and without therapist guidance, compared to a waitlist control condition, in the treatment of adults with SAD. In this randomized, clinical trial, we tested whether IPDT was superior to a waitlist control, and whether IPDT with therapeutic guidance was superior to unguided IPDT. Participants were recruited nationwide in Sweden. Eligible participants were ≥ 18 years old and scoring ≥ 60 on the Liebowitz Social Anxiety Scale self-report (LSAS-SR) whilst not fulfilling any of the exclusion criteria. Included participants were randomly assigned to IPDT with guidance (n = 60), IPDT without guidance (n = 61), or waitlist (n = 60). The IPDT intervention comprised eight self-help modules based on affect-focused dynamic therapy, delivered over 8 weeks on a secure online platform. The primary outcome was SAD symptoms severity measured weekly by the LSAS-SR. Primary analyses were calculated on an intention-to-treat sample including all participants randomly assigned. Secondary outcomes were depressive symptoms, generalized anxiety, quality of life, emotion regulation and defensive functioning. At post-treatment, both active treatments were superior to the waitlist condition with guided treatment exhibiting larger between group effects than unguided treatment (d = 1.07 95% CI [0.72, 1.43], p < .001 and d = 0.61, 95% CI [0.25, 0.98], p = .0018) on the LSAS-SR respectively. Guided IPDT lead to larger improvements than unguided IPDT (d = 0.46, 95% CI [0.11, 0.80], p < .01). At post-treatment, guided IPDT was superior to waitlist on all secondary outcome measures. Unguided IPDT was superior to waitlist on depressive symptoms and general anxiety, but not on emotion regulation, self-compassion or quality of life. Guided IPDT was superior to unguided PDT on depressive symptoms, with a trend towards superiority on a measure of generalized anxiety. At six and twelve month follow-up there were no significant differences between guided and unguided IPDT. In conclusion, IPDT shows promising effects in the treatment of SAD, with larger benefits from guided IPDT compared to non-guided, at least at post-treatment. This finding increases the range of accessible and effective treatment alternatives for adults suffering from SAD. The study was prospectively registered at ClinicalTrials (NCT05015166).

Uncertainty Breeds Anxiety and Depression: The Impact of the Russian Invasion in Ukraine on a Swedish Clinical Population Receiving Internet-Based Psychotherapy

Background

Recent global crises, such as the COVID-19 pandemic and the 2022 Russian invasion of Ukraine, have contributed to a rise in the global prevalence of anxiety and depressive disorders. This study examines the indirect impact of the Ukraine war on emotional disorders within a Swedish clinical population.

Method

The sample comprised participants (n = 1,222) actively engaged in an internet-based psychotherapeutic intervention (cognitive-behavioral, psychodynamic, and waitlist) when the war broke out. The Patient Health Questionnaire-9 scale and the Generalized Anxiety Disorder-7 scale were used to measure depression and anxiety.

Results

Anxiety and depressive symptom severity increased following the war's onset, with an average weekly increase of 0.77-points for anxiety (p = .001, Cohen's d = 0.08) and 0.09-points for depression (p = .70, Cohen's d = 0.01); however, the increase was negligible for depression. Furthermore, higher socioeconomic status (SES) predicted declines in depression and anxiety during the study period, with a 0.69-point average weekly decrease in anxiety (p < .001, Cohen's d = 0.32) and a 1.09-point decrease in depression (p < .001, Cohen's d = 0.48) per one unit increase in SES, suggesting that SES may serve as a protective factor that buffers against psychopathological development during crises.

Conclusions

These findings have implications for mitigating the development of psychopathology during crises and interpreting treatment efficacy estimates during such events. Our findings also emphasize the potential of internet-based psychotherapy in addressing emotional disorders during crises. This study presents up-to-date information about the reaction of treatment-seeking individuals to abrupt uncertainty.

The latest developments with internet-based psychological treatments for depression

INTRODUCTION

Internet-based psychological treatments for depression have been around for more than 20 years. There has been a continuous line of research with new research questions being asked and studies conducted.

AREAS COVERED

In this paper, the author reviews studies with a focus on papers published from 2020 and onwards based on a Medline and Scopus search. Internet-based cognitive behavior therapy (ICBT) programs have been developed and tested for adolescents, older adults, immigrant groups and to handle a societal crisis (e.g. COVID-19). ICBT works in regular clinical settings and long-term effects can be obtained. Studies on different treatment orientations and approaches such as acceptance commitment therapy, unified protocol, and tailored treatments have been conducted. Effects on quality-of-life measures, knowledge acquisition and ecological momentary assessment as a research tool have been reported. Factorial design trials and individual patient data meta-analysis are increasingly used in association with internet intervention research. Finally, prediction studies and recent advances in artificial intelligence are mentioned.

EXPERT OPINION

Internet-delivered treatments are effective, in particular if therapist guidance is provided. More target groups have been covered but there are many remaining challenges including how new tools like artificial intelligence will be used when treating depression.

Effects of non-pharmacological interventions on youth with internet addiction: a systematic review and meta-analysis of randomized controlled trials

Objective

To assess the overall effectiveness of non-pharmacological interventions on internet addiction (IA) in youth.

Method

Randomized controlled trials (RCTs) published from their inception to April 1, 2023 were searched in Cochrane, Embase, Medline, Web of Science, China National Knowledge Infrastructure, China Science and Technology Journal Database, Chinese BioMedical Literature Database, and WanFang Data. Two reviewers independently extracted data and evaluated bias using the Cochrane Risk of Bias tool.

Results

Sixty-six studies performed from 2007 to 2023, with a total of 4,385 participants, were identified. The NPIs included group counseling, cognitive behavioral therapy, sports intervention, combined interventions, eHealth, educational intervention, positive psychology intervention, sand play intervention, and electrotherapy. The results revealed that NPIs significantly reduced IA levels (standardized mean difference, SMD: -2.01, 95% confidence interval, CI: -2.29 to -1.73, I2 = 93.0%), anxiety levels (SMD: -1.07, 95%CI: -1.41 to -0.73, I2 = 72.4%), depression levels (SMD: -1.11, 95%CI: -1.52 to -0.7, I2 = 84.3%), and SCL-90 (SMD: -0.75, 95%CI: -0.97 to -0.54, I2 = 27.7%). Subgroup analysis stratified by intervention measure showed that cognitive behavioral therapy, group counseling, sports intervention, combined intervention, educational intervention, positive psychology intervention, sandplay intervention, and mobile health were all effective in relieving symptoms of IA except electrotherapy.

Conclusion

NPIs appear to be effective in the treatment of IA in youth, which would act as an alternative treatment of IA. Further studies with larger sample sizes and robust designs are needed.

Efficacy of internet-based cognitive-behavioral therapy for depression in adolescents: A systematic review and meta-analysis

Objective

Internet-based cognitive behavior therapy (ICBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in adolescents is limited. This systematic review and meta-analysis aims to comprehensively assess the efficacy of ICBT in addressing depression among adolescents.

Methods

Four electronic databases were searched on June 8, 2023. Randomized controlled trials (RCTs) evaluating the efficacy of ICBT for depression in adolescents were included. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook. Furthermore, the GRADE approach was employed to gauge the certainty of the obtained evidence. Meta-analysis was conducted using RevMan 5.4, and Egger's test was implemented through Stata for assessment of potential publication bias.

Results

A total of 18 RCTs involving 1683 patients were included. In comparison to control groups like attention control, waiting list, and treatment as usual, our meta-analysis findings elucidate a significant reduction in depression scores (SMD = -0.42, 95 % CI: [-0.74, -0.11], p < .05) as well as anxiety scores (SMD = -0.34, 95 % CI: [-0.60, -0.08], p < .05) in adolescents following ICBT interventions. Furthermore, the analysis indicated no notable distinctions in patient's quality of life (QoL) scores. (SMD = 0.12, 95 % CI: [-0.10, 0.34], p > .05).

Conclusion

Results provide evidence of the efficacy of ICBT to reduce depressive and anxiety symptoms in adolescents. These research findings are of vital significance for the establishment of evidence-based treatment guidelines in the digital era.

Trial registration

PROSPERO registration: CRD42021277562.

Use of social media in recruiting young people to mental health research: a scoping review

OBJECTIVES

This review explored the literature on the use of social media in recruiting young people, aged 13-18 years, to mental health research. It aimed to identify barriers and facilitators to recruitment and strategies to improve participation in future research.

DESIGN

Scoping review.

DATA SOURCES

Articles published between January 2011 and February 2023 were searched for on PubMed, Scopus, Medline (via EBSCOhost) and Cochrane Library databases.

ELIGIBILITY CRITERIA

Studies that outlined social media as a recruitment method and recruited participants aged 13-18 years.

DATA EXTRACTION AND SYNTHESIS

Data was extracted by two reviewers independently and cross-checked by a third reviewer. Data on study design, aims, participants, recruitment methods and findings related specifically to social media as a recruitment tool were collected.

RESULTS

24 journal articles met the inclusion criteria. Studies were predominantly surveys (n=13) conducted in the USA (n=16) recruiting via Facebook (n=16) and/or Instagram (n=14). Only nine of the included articles provided a summary of success and reviewed the efficacy of social media recruitment for young people in mental health research. Type of advertisement, the language used, time of day and the use of keywords were all found to be factors that may influence the success of recruitment through social media; however, as these are based on findings from a small number of studies, such potential influences require further investigation.

CONCLUSION

Social media recruitment can be a successful method for recruiting young people to mental health research. Further research is needed into recruiting socioeconomically marginalised groups using this method, as well as the effectiveness of new social media platforms.

REGISTRATION

Open Science Framework Registry (https://osf.io/mak75/).

Psychodynamic Formulation and Psychodynamic Psychotherapy for Pediatric Anxiety Disorders

Psychodynamic psychotherapy can be an effective treatment of pediatric anxiety disorders. Psychodynamic formulation can be easily integrated with other conceptualizations of anxiety (eg, biological/genetic, developmental, and social learning theory). Psychodynamic formulation helps determine whether anxiety symptoms represent innate biological responses, learned responses from early experiences, or defensive reactions to intrapsychic conflict. Child and Adolescent Anxiety Psychodynamic Psychotherapy and Psychoanalytic Child Therapy are two evidence-based manualized psychodynamic approaches to treating pediatric anxiety disorders.

"Good job!": Therapists' encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression

Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.