Two decades of digital interventions for anxiety disorders: a systematic review and meta-analysis of treatment effectiveness

The SoCAP (Social Communication, Affiliation, and Presence) Taxonomy of Social Features: Scoping Review of Commercially Available eHealth Apps

BACKGROUND

eHealth interventions have proven to be valuable resources for users with diverse mental and behavioral health concerns. As these technologies continue to proliferate, both academic researchers and commercial app creators are leveraging the use of features that foster a sense of social connection on these digital platforms. Yet, the literature often insufficiently represents the functionality of these key social features, resulting in a lack of understanding of how they are being implemented.

OBJECTIVE

This study aimed to conduct a methodical review of commercially available eHealth apps to establish the SoCAP (social communication, affiliation, and presence) taxonomy of social features in eHealth apps. Our goal was to examine what types of social features are being used in eHealth apps and how they are implemented.

METHODS

A scoping review of commercially available eHealth apps was conducted to develop a taxonomy of social features. First, a shortlist of the 20 highest-rated eHealth apps was derived from One Mind PsyberGuide, a nonprofit organization with trained researchers who rate apps based on their (1) credibility, (2) user experience, and (3) transparency. Next, both mobile- and web-based versions of each app were double-coded by 2 trained raters to derive a list of social features. Subsequently, the social features were organized by category and tested on other apps to ensure their completeness.

RESULTS

Four main categories of social features emerged: (1) communication features (videoconferencing, discussion boards, etc), (2) social presence features (chatbots, reminders, etc), (3) affiliation and identity features (avatars, profiles, etc), and (4) other social integrations (social network and other app integrations). Our review shows that eHealth apps frequently use resource-intensive interactions (eg, videoconferencing with a clinician and phone calls from a facilitator), which may be helpful for participants with high support needs. Furthermore, among commercially available eHealth apps, there is a strong reliance on automated features (eg, avatars, personalized multimedia, and tailored content) that enhance a sense of social presence without requiring a high level of input from a clinician or staff member.

CONCLUSIONS

The SoCAP taxonomy includes a comprehensive list of social features and brief descriptions of how these features work. This classification system will provide academic and commercial eHealth app creators with an understanding of the various social features that are commonly implemented, which will allow them to apply these features to enhance their own apps. Future research may include comparing the synergistic effects of various combinations of these social features.

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.

Evaluation of completely online psychotherapy with app-support versus therapy as usual for clients with depression or anxiety disorder: A retrospective matched cohort study investigating the effectiveness, efficiency, client satisfaction, and costs

INTRODUCTION

Depressive and anxiety disorders are common mental disorders ranking among the leading causes of global disease burden. Not all clients currently benefit from therapy and clients are looking for modern ways of therapy. Online psychotherapy is a promising option for better meeting clients' needs. Recently, a new psychotherapy concept has emerged that combines videoconferencing sessions with support through a mobile application. The latter allows for ecological momentary assessments and interventions, facilitates communication between patients and therapists in between sessions through chat, and allows for incorporating feedback-informed treatment principles.

MATERIAL AND METHODS

The study was a retrospective observational matched cohort study, comparing online psychotherapy with Therapy As Usual (TAU) for clients with depressive or anxiety disorders. Data were obtained via questionnaires, which are part of standard clinical care. Primary outcomes included general mental functioning, and symptoms of depression and anxiety. Secondary outcomes were efficiency, client satisfaction, and therapy costs. Primary endpoints were analyzed using linear mixed models analysis, with an interaction term between time and group. Secondary outcomes were analyzed using linear regression.

RESULTS

Larger improvements were observed in the online compared to the TAU group for general mental functioning and depressive disorder (i.e., General mental functioning: B = -8.50, 95 CI: -15.01 - -1.97, p = 0.011; Depressive disorder: B = - 3.66, 95 % CI: -5.79 - -1.54p < 0.01). No significant differences in change over time between the two groups were observed for anxiety disorder (B = -3.64, 95 % CI: (-13.10 - 5.82) p = 0.447). The total number of sessions was significantly higher in the online psychotherapy group than in TAU (B = 3.71, p < 0.01), although clients were matched on treatment time in weeks. Treatment session duration in minutes was comparable across the groups.

DISCUSSION

Online psychotherapy with app support showed to be a promising alternative to TAU for depressive and anxiety disorders. More research is needed to evaluate the effectiveness, cost-effectiveness and client satisfaction of online psychotherapy compared to TAU, such as randomized controlled trials or studies multiple baseline series designs, and in-depth qualitative research.

Examining a Fully Automated Mobile-Based Behavioral Activation Intervention in Depression: Randomized Controlled Trial

Background

Despite significant progress in our understanding of depression, prevalence rates have substantially increased in recent years. Thus, there is an imperative need for more cost-effective and scalable mental health treatment options, including digital interventions that minimize therapist burden.

Objective

This study focuses on a fully automated digital implementation of behavioral activation (BA)-a core behavioral component of cognitive behavioral therapy for depression. We examine the efficacy of a 1-month fully automated SMS text message-based BA intervention for reducing depressive symptoms and anhedonia.

Methods

To this end, adults reporting at least moderate current depressive symptoms (8-item Patient Health Questionnaire score ≥10) were recruited online across the United States and randomized to one of three conditions: enjoyable activities (ie, BA), healthy activities (ie, an active control condition), and passive control (ie, no contact). Participants randomized to enjoyable and healthy activities received daily SMS text messages prompting them to complete 2 activities per day; participants also provided a daily report on the number and enjoyment of activities completed the prior day.

Results

A total of 126 adults (mean age 32.46, SD 7.41 years) with current moderate depressive symptoms (mean score 16.53, SD 3.90) were recruited. Participants in the enjoyable activities condition (BA; n=39) experienced significantly greater reductions in depressive symptoms compared to participants in the passive condition (n=46). Participants in both active conditions-enjoyable activities and healthy activities (n=41)-reported reduced symptoms of anxiety compared to those in the control condition.

Conclusions

These findings provide preliminary evidence regarding the efficacy of a fully automated digital BA intervention for depression and anxiety symptoms. Moreover, reminders to complete healthy activities may be a promising intervention for reducing anxiety symptoms.

Skill enactment and knowledge acquisition among community users of digital mental health interventions: qualitative study with thematic analysis

BACKGROUND

The acquisition of knowledge and use of skills from digital mental health interventions (DMHIs) are considered important for effectiveness. However, our understanding of user experiences implementing skills learned from these interventions is limited, particularly outside of research trials. This qualitative study aimed to investigate how community users learn and apply knowledge and skills from DMHIs based on cognitive behavioural therapy (CBT) in daily life. The study also examined factors influencing the selection and use of skills and explored perceived changes in mental health resulting from the intervention.

METHODS

Thirteen adults aged 26 to 66 years (10 females) were recruited using social media advertising and participated in semi-structured interviews by telephone or videoconference. All participants were living in Australia and had used a digital CBT program within the past 3 months. Interviews lasted on average 45 min. Transcripts were analysed using theoretical thematic analysis.

RESULTS

Participants demonstrated high levels of program engagement. Findings were organised into three topics with six major themes. Participants reported that their chosen intervention reinforced existing knowledge and fostered new skills and insights (Topic 1, Theme 1: knowledge consolidation). Most described actively applying skills (Topic 1, Theme 2: active approach to skill enactment), although the extent of learning and range of skills enacted varied across participants. Influences on skill selection included the perceived relevance of intervention strategies to the user's needs and personal characteristics (Topic 2, Theme 1: relevance of intervention strategies), as well as the perceived or experienced effectiveness of those strategies (Topic 2, Theme 2: perceived and experienced benefit). Challenges to ongoing skill enactment included time scarcity, prioritisation difficulties, and lack of motivation (Topic 2, Theme 3: navigating time constraints and low motivation). Improvements in mental health were generally modest and attributed mainly to participants' proactive efforts (Topic 3, Theme 1: perceived changes).

CONCLUSIONS

DMHIs may reinforce existing understanding of psychotherapeutic strategies, offer new knowledge, and encourage the application of skills in everyday life among community users who actively engage with these interventions. Future research should prioritise personalising DMHIs and investigating methods to optimise the acquisition, retention, and sustained application of knowledge and skills.

Efficacy of technology-based mental health interventions in minimizing mental health symptoms among in immigrants, asylum seekers or refugees; systematic review

Digital health technologies may offer an alternate approach to augmenting the established mental health care delivery systems for migrants and promoting their mental well-being. This review aims to provide a broad examination of literature, to determine the impact of technology-based interventions on outcomes of immigrants and refugees experiencing mental health symptoms associated with pre-and postmigration stress (depression, anxiety, psychological stress, PTSD). We searched five electronic databases (PubMed, Embase, PsycINFO, Web of Science, and the ACM digital library). We included studies that looked at the effectiveness of any technologybased intervention (internet or phone-based, telepsychiatry, telemedicine, digital technology, videoconferencing, or tele video). We limited our search to articles written in English and published up until January 2202. Two reviewers independently extracted article data and evaluated the quality of studies using the Cochrane risk-of-bias criteria and ROBINS-I risk of bias evaluation tool. We found scant evidence that the use of digital interventions, such as mobile-based therapies, video conferencing, and digital platforms, is associated with a statistically significant reduction in depressive and anxious symptoms among immigrants and refugees. In the included trials, no evidence of a substantial decrease in PTSD symptoms was found following the use of a self-help mobile app. Our systematic review revealed intriguing but limited evidence that digital psychological therapies can reduce depression in immigrants and refugees. Future study with a randomized experimental design is required to examine the effectiveness of digital treatments in lowering the impacts of mental health outcomes among immigrants.

Efficacy of a Mobile App-Based Intervention for Young Adults With Anxiety Disorders: A Randomized Clinical Trial

Importance

Anxiety disorders are prevalent and undertreated among young adults. Digital mental health interventions for anxiety are promising but limited by a narrow range of therapeutic components and low user engagement.

Objective

To investigate the efficacy of and engagement with Maya, a scalable, self-guided, comprehensive mobile cognitive behavioral therapy (CBT) intervention with embedded engagement features, comparing the effects of 3 incentive conditions.

Design, Setting, and Participants

This randomized clinical trial recruited young adults aged 18 to 25 years with anxiety disorders through online advertisements and outpatient psychiatry clinics at Weill Cornell Medicine. Enrollment was between June 16, 2021, and November 11, 2022. Data analysis was performed from December 21, 2022, to June 14, 2024.

Intervention

Participants received a 6-week program of the intervention and were randomized to 1 of 3 different text message-based incentive conditions (gain-framed, loss-framed, or gain-social support).

Main Outcomes and Measures

The primary outcome was change in anxious symptoms from baseline to end of treatment, as measured by the Hamilton Anxiety Rating Scale (HAM-A). The Anxiety Sensitivity Index and the Leibowitz Social Anxiety Scale scores were secondary measures.

Results

The sample consisted of 59 participants (mean [SD] age, 23.1 [1.9] years; 46 [78%] female; 22 [37%] Asian, 3 [5%] Black, 5 [8%] Hispanic or Latino, 1 [2%] American Indian or Alaska Native, 25 [42%] White, and 6 [10%] >1 race; 32 [54%] college-educated and 12 [20%] graduate or professional school-educated; mean [SD] baseline HAM-A score, 15.0 [6.5]). Anxiety, measured by HAM-A, decreased across conditions from baseline to end of the intervention (mean difference, -5.64; 95% CI, -7.23 to -4.05), and symptomatic improvement was maintained at the week 12 follow-up (baseline to follow-up mean difference, -5.67; 95% CI, -7.29 to -4.04). However, there was no evidence that change in anxiety differed by incentive condition (loss-framed vs gain-social support mean difference, -1.40; 95% CI, -4.72 to 1.93; gain-framed vs gain-social support mean difference, 1.38; 95% CI, -1.19 to 3.96). Secondary anxiety measures (Anxiety Sensitivity Index and Liebowitz Social Anxiety Scale scores) showed a similar pattern of improvement, with no evidence of differences between incentive conditions. Participants completed most of the 12 sessions (mean [SD], 10.8 [2.1]; 95% CI, 10.3-11.4), and User Mobile Application Rating Scale app quality ratings exceeded the published threshold for acceptability at all study visits. There was no evidence that either session completion or app quality ratings differed by incentive condition.

Conclusions and Relevance

In this randomized clinical trial of an app-based intervention for anxiety, the primary hypothesis that improvement in anxiety would be greatest in the condition using gain of points plus social incentives was not supported; however, the results suggest that a CBT application incorporating a full suite of CBT skills and embedded user engagement features was efficacious in improving symptoms in young adults with anxiety disorders. Given these findings, digital interventions represent a promising step toward wider dissemination of high-quality, evidence-based interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT05130281.

Assessing the effectiveness of internet-based interventions for mental health outcomes: an umbrella review

Internet-based interventions (IBIs) for behavioural health have been prevalent for over two decades, and a growing proportion of individuals with mental health concerns prefer these emerging digital alternatives. However, the effectiveness and acceptability of IBIs for various mental health disorders continue to be subject to scholarly debate. We performed an umbrella review of meta-analyses (MAs), conducting literature searches in PubMed, Web of Science, Embase, Cochrane and Ovid Medline from their inception to 17 January 2023. A total of 87 MAs, reporting on 1683 randomised controlled trials and 295 589 patients, were included. The results indicated that IBIs had a moderate effect on anxiety disorder (standardised mean difference (SMD)=0.53, 95% CI 0.44 to 0.62) and post-traumatic stress disorder (PTSD) (SMD=0.63, 95% CI 0.38 to 0.89). In contrast, the efficacy on depression (SMD=0.45, 95% CI 0.39 to 0.52), addiction (SMD=0.23, 95% CI 0.16 to 0.31), suicidal ideation (SMD=0.23, 95% CI 0.16 to 0.30), stress (SMD=0.41, 95% CI 0.33 to 0.48) and obsessive-compulsive disorder (SMD=0.47, 95% CI 0.22 to 0.73) was relatively small. However, no significant effects were observed for personality disorders (SMD=0.07, 95% CI -0.13 to 0.26). Our findings suggest a significant association between IBIs and improved mental health outcomes, with particular effectiveness noted in treating anxiety disorders and PTSD. However, it is noteworthy that the effectiveness of IBIs was impacted by high dropout rates during treatment. Furthermore, our results indicated that guided IBIs proved to be more effective than unguided ones, playing a positive role in reducing dropout rates and enhancing patient adherence rates. PROSPERO registration number: CRD42023417366.

Improving mental health by improving the mental health literacy? Study protocol for a randomised controlled evaluation of an e-mental health application as a preventive intervention for adolescents and young adults

Background

From the age of 14, many adolescents enter a vulnerable developmental phase, with a sharp increase in mental illness at 16. The COVID19 pandemic has further exacerbated this issue. Hence, universal and easily accessible prevention in the young is needed. E-mental health interventions are on the rise due to numerous benefits such as potential low-costs, low-threshold and high scalability. However, effectiveness and acceptance of mobile health (mHealth) preventive interventions remain unresearched.

Method

In a two-armed, randomised controlled study design adolescents and young adults from 14 years old will be recruited. Following an initial baseline assessment, they will be randomised to a) the intervention group (IG, n = 75), which will receive a mHealth intervention (the application 'Mental Health Guide', co-developed by lived experience experts) or b) the waiting list control group (CG, n = 75). Both groups will be followed up after 3 and 6 months following post assessment. We hypothesize an increase in mental health literacy in the IG compared to the CG for post and follow-up assessment (primary outcome: Mental Health Literacy Scale). In addition, we expect an improvement in mental health and psychological well-being, improved emotion regulation, reduced psychological distress, as well as good quality ratings in usability and acceptance in the use of the 'Mental Health Guide' We performed multiple simulations of possible outcome scenarios, incorporating an array of factors, to generate realistic datasets and obtain accurate estimates of statistical power.

Conclusion

As a first-of-its-kind in this field, this study investigates whether a mHealth intervention based on mental health literacy may improve the mental health literacy and further aspects of psychological functioning of young people in a vulnerable phase. Furthermore, the results promise to provide important knowledge of how universal prevention may be implemented with low costs for diverse populations.

Trial registration

This trial was registered in the DRKS register (DRKS-ID: DRKS00031810) on 23 June 2023.

Predictors of adherence to a publicly available self-guided digital mental health intervention

Low adherence to self-guided digital mental health interventions (DMHIs) have raised concerns about their real-world effectiveness. Naturalistic data from self-guided DMHIs are often not available, hindering our ability to assess adherence among real-world users. This study aimed to analyze 3 years of user data from the public launch of an empirically supported 12-session self-guided DMHI, to assess overall program adherence rates and explore predictors of adherence. Data from 984 registered users were analyzed. Results showed that only 14.8% of users completed all 12 modules and 68.6% completed less than half of the modules. Users who were younger, had milder depression, had never seen a mental health provider, and who rejected signing-up for weekly program emails completed significantly more modules. Results add to concerns about the generalizability of controlled research on DMHIs due to lower adherence outside of research trials. This study highlights the potential of user data in identifying key factors that may be related to adherence. By examining adherence patterns among different sub-sets of users, we can pinpoint and focus on individuals who may adhere and benefit more from self-guided programs. Findings could also have implications for guiding intervention personalization for individuals who struggle to complete DMHIs.

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study

INTRODUCTION

Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.

OBJECTIVE

To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.

METHODS

Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.

RESULTS

Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists' point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.

CONCLUSIONS

Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

Demographic and clinical characteristics associated with anxiety and depressive symptom outcomes in users of a digital mental health intervention incorporating a relational agent

BACKGROUND

Digital mental health interventions (DMHIs) may reduce treatment access issues for those experiencing depressive and/or anxiety symptoms. DMHIs that incorporate relational agents may offer unique ways to engage and respond to users and to potentially help reduce provider burden. This study tested Woebot for Mood & Anxiety (W-MA-02), a DMHI that employs Woebot, a relational agent that incorporates elements of several evidence-based psychotherapies, among those with baseline clinical levels of depressive or anxiety symptoms. Changes in self-reported depressive and anxiety symptoms over 8 weeks were measured, along with the association between each of these outcomes and demographic and clinical characteristics.

METHODS

This exploratory, single-arm, 8-week study of 256 adults yielded non-mutually exclusive subsamples with either clinical levels of depressive or anxiety symptoms at baseline. Week 8 Patient Health Questionnaire-8 (PHQ-8) changes were measured in the depressive subsample (PHQ-8 ≥ 10). Week 8 Generalized Anxiety Disorder-7 (GAD-7) changes were measured in the anxiety subsample (GAD-7 ≥ 10). Demographic and clinical characteristics were examined in association with symptom changes via bivariate and multiple regression models adjusted for W-MA-02 utilization. Characteristics included age, sex at birth, race/ethnicity, marital status, education, sexual orientation, employment status, health insurance, baseline levels of depressive and anxiety symptoms, and concurrent psychotherapeutic or psychotropic medication treatments during the study.

RESULTS

Both the depressive and anxiety subsamples were predominantly female, educated, non-Hispanic white, and averaged 38 and 37 years of age, respectively. The depressive subsample had significant reductions in depressive symptoms at Week 8 (mean change =-7.28, SD = 5.91, Cohen's d = -1.23, p < 0.01); the anxiety subsample had significant reductions in anxiety symptoms at Week 8 (mean change = -7.45, SD = 5.99, Cohen's d = -1.24, p < 0.01). No significant associations were found between sex at birth, age, employment status, educational background and Week 8 symptom changes. Significant associations between depressive and anxiety symptom outcomes and sexual orientation, marital status, concurrent mental health treatment, and baseline symptom severity were found.

CONCLUSIONS

The present study suggests early promise for W-MA-02 as an intervention for depression and/or anxiety symptoms. Although exploratory in nature, this study revealed potential user characteristics associated with outcomes that can be investigated in future studies.

TRIAL REGISTRATION

This study was retrospectively registered on ClinicalTrials.gov (#NCT05672745) on January 5th, 2023.

An app-based training for adolescents with problematic digital-media use and their parents (Res@t digital): protocol for a cluster-randomized clinical trial

Background

Digital media-use disorders (DMUD) in adolescents are a rising phenomenon associated with psychological distress, comorbid mental disorders, and high burden on affected families. Since the ICD-11 introduced criteria for gaming disorder, these can now be transferred to describe additional DMUD associated with social media platforms and streaming services. Most evidence for effective treatments comes from cognitive-behavioral therapy (CBT). However, interventions based on theoretical models for adolescents and their parents are widely missing, leading to a significant clinical gap.

Methods

Res@t digital (Resource-Strengthening Training for Adolescents with Problematic Digital-Media Use and their Parents) is the app-based translation of the first model-based digital intervention for adolescents with DMUD and their parents based on CBT. It comprises separate but content-related modules for adolescents (Res@t-A) and parents (Res@t-P), applying multimodal techniques. The effectiveness of Res@t will be evaluated within a multicenter cluster-randomized controlled evaluator-blinded pre-post follow-up trial with the waitlist control group (CG). In addition to the Res@t program in the intervention group, both groups will receive treatment as usual within primary child and adolescent psychiatric/psychotherapeutic healthcare. The primary outcome addresses DMUD symptom reduction after 10 weeks. Secondary outcomes are related to a reduction in psychological and family-related problems and an increase in parental self-efficacy. All outcomes will be assessed using standardized self-report measures. A total of 1,334 participating adolescent-parent dyads from a large clinical network throughout Germany are planned to be included in the primary analyses based on an intention-to-treat approach, applying linear mixed models.

Discussion

Assuming superiority of Res@t over the control condition, the intervention has the potential to provide evidence-based treatment for a significant number of help-seeking families, supporting local healthcare structures and resources. It is a promising program for practicable implementation and flexible use in different settings.

Clinical trial registration

https://drks.de, DRKS00031043.

Small Steps over time: A longitudinal usability test of an automated interactive text messaging intervention to support self-management of depression and anxiety symptoms

BACKGROUND

Digital mental health interventions (DMHIs) offer potential solutions for addressing mental health care gaps, but often suffer from low engagement. Text messaging is one promising medium for increasing access and sustaining user engagement with DMHIs. This paper examines the Small Steps SMS program, an 8-week, automated, adaptive text message-based intervention for depression and anxiety.

METHODS

We conducted an 8-week longitudinal usability test of the Small Steps SMS program, recruiting 20 participants who met criteria for major depressive disorder and/or generalized anxiety disorder. Participants used the automated intervention for 8 weeks and completed symptom severity and usability self-report surveys after 4 and 8 weeks of intervention use. Participants also completed individual interviews to provide feedback on the intervention.

RESULTS

Participants responded to automated messages on 70 % of study days and with 85 % of participants sending responses to messages in the 8th week of use. Usability surpassed established cutoffs for software that is considered acceptable. Depression symptom severity decreased significantly over the usability test, but reductions in anxiety symptoms were not significant. Participants noted key areas for improvement including addressing message volume, aligning message scheduling to individuals' availability, and increasing the customizability of content.

LIMITATIONS

This study does not contain a control group.

CONCLUSIONS

An 8-week automated interactive text messaging intervention, Small Steps SMS, demonstrates promise with regard to being a feasible, usable, and engaging method to deliver daily mental health support to individuals with symptoms of anxiety and depression.

E-therapists' views on the acceptability and feasibility of an internet-administered, guided, low-intensity cognitive behavioural therapy intervention for parents of children treated for cancer: A qualitative study

Background

Childhood cancer treatment completion can be a period of vulnerability for parents and is associated with mental health difficulties such as depression and anxiety. We developed an internet-administered, guided, low-intensity cognitive behavioural therapy-based self-help intervention (EJDeR) for parents delivered on the U-CARE-portal (Portal). The acceptability and feasibility of EJDeR and study procedures were examined using a single-arm feasibility trial (ENGAGE). Results indicated that EJDeR and ENGAGE study procedures are acceptable and feasible, however, a need for clinical and technical modifications to EJDeR and refinements to ENGAGE study procedures was identified.

Objectives

This study aimed to explore the acceptability and feasibility of EJDeR and ENGAGE study procedures from the perspective of e-therapists to inform clinical and technical modifications to EJDeR and refinements to study procedures prior to progression to a superiority randomised controlled trial.

Methods

We conducted semi-structured interviews with 10 e-therapists. Data were analysed using manifest content analysis.

Results

We identified three categories relating to the acceptability and feasibility of EJDeR: (a) Support to e-therapists (subcategories: Clinical supervision and Technical difficulties); (b) Guidance to parents (subcategories: Support protocols and Synchronous communication); and (c) Content (subcategories: Relevancy of the intervention and Pacing of the intervention). We identified four categories relating to the acceptability and feasibility of study procedures: (a) Recruitment and training of e-therapists (subcategories: Definition of the role and Training program); (b) Retention of parents (subcategories: Parent suitability and screening and Frequency of weekly Portal assessments); (c) Retention of e-therapists (subcategories: Administrative requirements and Communication with the research team); and (d) The Portal.

Conclusions

EJDeR and study procedures were considered acceptable and feasible, however, clinical and technical modifications and refinements to study procedures were suggested to enhance acceptability and feasibility. Results may also inform implementation considerations for both EJDeR and other similar digital psychological interventions.

Trial registration number

ISRCTN 57233429.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

Seeking help for mental health during the COVID-19 pandemic: A longitudinal analysis of adults' experiences with digital technologies and services

The COVID-19 pandemic brought about dramatic changes in how patients access healthcare from its outset. Lockdown restrictions and remote working led to a proliferation of digital technologies and services, which also impacted mental health provisions. Against the backdrop of new and changing support services, along with an unprecedented emphasis on mental health, relatively little is known about how adults sought out and received support for their mental health during this period. With a sample of 27,574 adults assessed longitudinally online over 12 months of the pandemic in the UK, we analysed reports of help-seeking for mental health, as well as sources of treatment or support and the perceived helpfulness of treatments received. We observed that the proportions of participants who reported seeking help remained relatively consistent throughout the 12-month period (ranging from 12.6% to 17.0%). Online talking therapies were among the most frequently sought sources (15.3%), whereas online self-guided treatments were among the least frequently sought sources (5%). Telephone lines, both NHS and non-governmental, had marked treatment 'gaps'. These treatment gaps, where individuals sought treatment but did not receive it, were especially evident for men and older adults. Our findings underscore online talking therapies as being a widely-sought and helpful source of mental health support. This is important given the current global need for accessible treatment options.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Feasibility, Perceived Impact, and Acceptability of a Socially Assistive Robot to Support Emotion Regulation With Highly Anxious University Students: Mixed Methods Open Trial

BACKGROUND

Mental health difficulties among university students have been rising rapidly over the last decade, and the demand for university mental health services commonly far exceeds available resources. Digital interventions are seen as one potential solution to these challenges. However, as in other mental health contexts, digital programs often face low engagement and uptake, and the field lacks usable, engaging, evidence-supported mental health interventions that may be used flexibly when students need them most.

OBJECTIVE

The aim of this study is to investigate the feasibility and acceptability of a new, in situ intervention tool (Purrble) among university students experiencing anxiety. As an intervention, Purrble was designed to provide in situ support for emotion regulation (ER)-a well-known transdiagnostic construct-directly in the moments when individuals are facing emotionally challenging situations. A secondary aim is to consider the perceived impact of Purrble on youth mental health, as reported by students over a 7-week deployment.

METHODS

A mixed methods open trial was conducted with 78 under- and postgraduate students at Oxford University. Participants were recruited based on moderate to high levels of anxiety measured by Generalized Anxiety Disorder-7 at baseline (mean 16.09, SD 3.03). All participants had access to Purrble for 7 weeks during the spring term with data on their perceived anxiety, emotion dysregulation, ER self-efficacy, and engagement with the intervention collected at baseline (pre), week 4 (mid), and week 8 (postintervention). Qualitative responses were also collected at the mid- and postintervention points.

RESULTS

The findings demonstrated a sustained engagement with Purrble over the 7-week period, with the acceptability further supported by the qualitative data indicating that students accepted Purrble and that Purrble was well-integrated into their daily routines. Exploratory quantitative data analysis indicated that Purrble was associated with reductions in student anxiety (dz=0.96, 95% CI 0.62-1.29) and emotion dysregulation (dz=0.69, 95% CI 0.38-0.99), and with an increase in ER self-efficacy (dz=-0.56, 95% CI -0.86 to -0.26).

CONCLUSIONS

This is the first trial of a simple physical intervention that aims to provide ongoing ER support to university students. Both quantitative and qualitative data suggest that Purrble is an acceptable and feasible intervention among students, the engagement with which can be sustained at a stable level across a 7-week period while retaining a perceived benefit for those who use it (n=32, 61% of our sample). The consistency of use is particularly promising given that there was no clinician engagement or further support provided beyond Purrble being delivered to the students. These results show promise for an innovative intervention model, which could be complementary to the existing interventions.

Real-World User Demographics of Three Web-Based Digital Mental Health Interventions Provided by the US Department of Veterans Affairs: Observational Study Using Web Analytics Data

BACKGROUND

Unguided digital mental health interventions (UDMHIs) have the potential to provide low-cost and effective mental health care at scale. Controlled trials have demonstrated the efficacy of UDMHIs to address mental health symptoms and conditions. However, few previous publications have described the demographics of real-world users of UDMHIs that are freely available to the public. The US Department of Veterans Affairs has created and hosts several UDMHIs on its Veteran Training Portal website. These web-based, free-to-use, and publicly available UDMHIs include Path to Better Sleep, Anger and Irritability Management Skills, and Moving Forward, which focus on insomnia, problematic anger, and depression symptoms, respectively.

OBJECTIVE

This study aimed to examine the user demographics of these 3 UDMHIs in the year 2021. In addition, it aimed to compare the age and gender distribution of the users of those 3 UDMHIs with one another and with the age and gender distribution of the total US veteran population.

METHODS

Google Analytics was used to collect user data for each of the 3 UDMHIs. The age and gender distribution of the users of each UDMHI was compared with that of the other UDMHIs as well as with that of the overall US veteran population using chi-square tests. Information on the total number of users, the country they were in, and the devices they used to access the UDMHIs was also collected and reported.

RESULTS

In 2021, the 3 UDMHIs together recorded 29,306 unique users. The estimated age range and gender were available for 24.12% (7068/29,306) of those users. Each UDMHI's age and gender distribution significantly differed from that of the other UDMHIs and from that of the overall US veteran population (P<.001 on all chi-square tests). Women and younger age groups were overrepresented among UDMHI users compared with the overall US veteran population. The majority of devices used to access the UDMHIs were desktop or laptop devices, although a substantial proportion of devices used were mobile devices (10,199/29,752, 34.28%). Most users (27,789/29,748, 93.41%) were located in the United States, with users from Canada, the United Kingdom, and Australia accounting for another 2.61% (775/29,748) of total users.

CONCLUSIONS

Our use of Google Analytics data provided useful information about the users of 3 free and publicly available UDMHIs provided by the US Department of Veterans Affairs. Although our findings should be considered in light of the limitations of autonomously collected web analytics data, they still offer useful information for health care policy makers, administrators, and UDMHI developers.

Online versus in-person delivery of cognitive behaviour therapy for obsessive compulsive disorder: An examination of effectiveness

Cognitive behavioural therapy (CBT) including exposure and response prevention is the first-line psychological treatment for obsessive compulsive disorder (OCD). Given changes in the clinical landscape, there are increasing efforts to evaluate its effectiveness in online contexts. Mirroring the traditional in-person delivery, few studies have assessed the role of therapist-guided, manual-based CBT for OCD delivered in real-time via videoconferencing methods. The present study sought to fill this gap by comparing in-person and online delivery of group-based CBT for the treatment of OCD. A convenience sample of participants with moderate to severe OCD (n = 144) were recruited from a naturalistic database from two large OCD specialty assessment and treatment centres. Patients received group-based CBT that was provided in-person (pre-COVID-19 pandemic; March 2018 to March 2020) or online via videoconferencing (during the COVID-19 pandemic; March 2020 to April 2021). In both delivery methods, treatment consisted of 2-h weekly sessions led by trained clinicians. Analyses revealed that, regardless of treatment modality, both in-person and online groups demonstrated significant, reliable, and statistically equivalent improvements in OCD symptoms post-treatment. Videoconferenced, clinician-led CBT may be a promising alternative to in-person delivery for those with moderate to severe OCD symptoms.

A Novel and Integrated Digitally Supported System of Care for Depression and Anxiety: Findings From an Open Trial

BACKGROUND

The global burden of anxiety and depression has created an urgent need for scalable approaches to increase access to evidence-based mental health care. The Screening and Treatment for Anxiety and Depression (STAND) system of care was developed to meet this need through the use of internet-connected devices for assessment and provision of treatment. STAND triages to level of care (monitoring only, digital therapy with coaches, digital therapy assisted by clinicians in training, and clinical care) and then continuously monitors symptoms to adapt level of care. Triaging and adaptation are based on symptom severity and suicide risk scores obtained from computerized adaptive testing administered remotely.

OBJECTIVE

This article discusses how the STAND system of care improves upon current clinical paradigms, and presents preliminary data on feasibility, acceptability, and effectiveness of STAND in a sample of US-based university students.

METHODS

US-based university students were recruited and enrolled in an open trial of the STAND system of care. Participants were triaged based on initial symptom severity derived from a computerized adaptive test and monitored over 40 weeks on anxiety, depression, and suicide risk to inform treatment adaptation and evaluate preliminary effectiveness.

RESULTS

Nearly 5000 students were screened and 516 received care. Depression and anxiety severity scores improved across all tiers (P<.001 in all cases). Suicide risk severity improved in the highest tier (ie, clinical care; P<.001). Acceptability and feasibility were demonstrated.

CONCLUSIONS

STAND is a feasible and acceptable model of care that can reach large numbers of individuals. STAND showed preliminary effectiveness on all primary outcome measures. Current directions to improve STAND are described.

The Role of Aesthetics in Intentions to Use Digital Health Interventions

Digital interventions are increasingly recognised as cost-effective treatment solutions for a number of health concerns, but adoption and use of these interventions can be low, affecting outcomes. This research sought to identify how individual aesthetic facets and perceived trust may influence perceptions toward and intentions to use an online health intervention by building on the Technology Acceptance Model, where perceived attractiveness, perceived usefulness, perceived ease of use and perceived enjoyment are thought to predict behavioural intentions towards a website. An online questionnaire study assessed perceptions of nine stimuli varying in four aesthetic facets (simplicity, diversity, colour & craftsmanship), utilising a quasi-experimental within-subjects design with a repetition among three different groups: individuals from the general population who were shown stimuli referring to general health (GP-H) (N = 257); individuals experiencing an eating disorder and shown stimuli referring to eating disorders (ED-ED) (N = 109); and individuals from the general population who were shown stimuli referring to eating disorders (GP-ED) (N = 235). Linear mixed models demonstrated that perceptions of simplicity and craftsmanship significantly influenced perceptions of usefulness, ease of use, enjoyment and trust, which in turn influenced behavioural intentions. This study demonstrates that developing the TAM model to add a further construct of perceived trust could be beneficial for digital health intervention developers. In this study, simplicity and craftsmanship were identified as the aesthetic facets with the greatest impact on user perceptions of digital health interventions.

Universal, selective and indicated interventions for supporting mental health at the workplace: an umbrella review of meta-analyses

The current umbrella review aimed to assess and summarise evidence on universal, selective and indicated interventions for mental health at the workplace. This umbrella review forms one of the evidence reviews which were commissioned by the WHO to develop global guidelines on mental health at work. We conducted systematic searches in five bibliographic databases (PubMed, Embase, PsycINFO, Cochrane and Global Medicus Index) and included meta-analyses of randomised trials examining psychosocial, physical activity and lifestyle interventions delivered to all general workers (universal interventions), at-risk workers (selective interventions) and workers already experiencing symptoms of mental disorders (indicated interventions). We included outcomes from seven domains: symptoms of mental health conditions, positive mental health, quality of life, work-related outcomes, substance use, suicide-related outcomes and potential adverse effects. We identified 16 meta-analyses producing 66 pooled effect sizes of the examined interventions, mostly on symptoms of mental health conditions (n=43 pooled effect sizes) (eg, burnout, insomnia, stress) and positive mental health (n=15) (eg, well-being). Most of the evidence on universal, selective and indicated interventions was focused on psychosocial interventions, showing small to moderate effects across the various outcomes. Certainty levels according to GRADE (Grading of Recommendations Assessment, Development and Evaluation) were low to very low in almost all of the examined outcomes. The results of existing meta-analyses are promising for the use of preventative and early treatment interventions in the workplace. However, the quality and certainty of the evidence were very modest, and further research on the effectiveness of these interventions is warranted.

Internet-delivered psychological treatment as an add-on to treatment as usual for common mental disorders: A systematic review with meta-analysis of randomized trials

BACKGROUND

Psychological treatments for common mental disorders are increasingly being delivered remotely via the internet. Evidence suggests that internet-delivered cognitive behavioural therapy (iCBT) is superior to waitlist. However, the benefits are unclear of using this treatment modality as an add-on to treatment as usual (TAU) in regular healthcare.

METHODS

The literature was systematically searched up to August 2021 for randomized trials of internet-delivered psychological treatments using TAU as the comparator. Eligible participants were diagnosed with depressive, anxiety, obsessive-compulsive, or trauma- and stress-related disorders. Outcomes of interest were symptoms, functioning, quality of life, healthcare utilization, and negative effects. Results were synthesized using random-effects meta-analyses. Quality of evidence was assessed using GRADE.

RESULTS

The included studies evaluated iCBT for adults with depression (k = 9), depressive or anxiety disorders (k = 4), and post-traumatic stress disorder (k = 2) and were conducted in primary care or similar settings. For depression, low-certainty evidence suggested beneficial short-term effects on symptoms (g = -0.23; 95 % CI: = -0.37, -0.09), response rate (OR = 2.46; 1.31, 4.64), and remission (OR = 1.70; 1.19, 2.42;). The certainty of evidence was very low for long-term effects, other outcomes, and other disorders.

LIMITATIONS

TAU varied across studies and was often insufficiently described.

CONCLUSIONS

iCBT as a complement to usual care for adult with depression may result in a small incremental effect, which potentially could be clinically important. Studies are lacking for several common disorders and for children, adolescents, and the elderly. More robust studies of long-term effects are also needed, to better inform clinical decision-making.

CBT treatment delivery formats for panic disorder: a systematic review and network meta-analysis of randomised controlled trials

Several in-person and remote delivery formats of cognitive-behavioural therapy (CBT) for panic disorder are available, but up-to-date and comprehensive evidence on their comparative efficacy and acceptability is lacking. Our aim was to evaluate the comparative efficacy and acceptability of all CBT delivery formats to treat panic disorder. To answer our question we performed a systematic review and network meta-analysis of randomised controlled trials. We searched MEDLINE, Embase, PsycINFO, and CENTRAL, from inception to 1st January 2022. Pairwise and network meta-analyses were conducted using a random-effects model. Confidence in the evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). The protocol was published in a peer-reviewed journal and in PROSPERO. We found a total of 74 trials with 6699 participants. Evidence suggests that face-to-face group [standardised mean differences (s.m.d.) -0.47, 95% confidence interval (CI) -0.87 to -0.07; CINeMA = moderate], face-to-face individual (s.m.d. -0.43, 95% CI -0.70 to -0.15; CINeMA = Moderate), and guided self-help (SMD -0.42, 95% CI -0.77 to -0.07; CINeMA = low), are superior to treatment as usual in terms of efficacy, whilst unguided self-help is not (SMD -0.21, 95% CI -0.58 to -0.16; CINeMA = low). In terms of acceptability (i.e. all-cause discontinuation from the trial) CBT delivery formats did not differ significantly from each other. Our findings are clear in that there are no efficacy differences between CBT delivered as guided self-help, or in the face-to-face individual or group format in the treatment of panic disorder. No CBT delivery format provided high confidence in the evidence at the CINeMA evaluation.

Promoting engagement with self-guided digital therapeutics for mental health: Insights from a cross-sectional survey of end-users

BACKGROUND

Poor engagement has hindered the dissemination of self-guided digital therapeutics for mental health. Evidence on the efficacy of technology-supported strategies designed for increasing engagement with these interventions is currently inconclusive. Few studies have examined user perceptions of such strategies, which could yield key insights for enhancing their effectiveness.

METHODS

Two hundred and eleven participants completed a cross-sectional online survey. All participants were aged 18 years and above, living in Australia, fluent in English, and self-reported prior use of digital therapeutics for mental health needs. Survey items elicited participants' views on factor(s) contributing to their engagement/disengagement with digital therapeutics, and perceptions of engagement strategies, including: automated electronic reminders, fun facts, quizzes, and social media platforms. χ² tests of independence were used to analyse nominal data. Inductive thematic analysis was used to analyse free-text data.

RESULTS

Factors facilitating engagement included digestible content, assurance of confidentiality, and esthetically appealing design. Factors hindering engagement included lack of time, forgetfulness, and lack of perceived intervention efficacy. Participants had mixed views over the feasibility and acceptability of the strategies explored toward promoting engagement.

CONCLUSIONS

Regardless of strategy type, succinct and easily applicable content was identified as an important feature for promoting engagement. Conversely, content that could trigger psychological distress among intervention users should be avoided. Overall, the diverse range of user perspectives highlighted that engagement strategies for any specific digital intervention should be co-designed with individuals with lived experience of mental health difficulties.

Adherence and effectiveness of an emotion-based psychodynamic online self-help during and after inpatient and day-care psychotherapy: Results of a naturalistic study

BACKGROUND

Internet-based mental health interventions are considered effective in providing low-threshold support for people with mental health disorders. However, there is a lack of research investigating the transferability of such online programs into routine care settings. Low treatment adherence and problems with technical implementation often limit a successful transfer into clinical routines. This naturalistic study aims to identify influencing factors on program adherence in patients who participated in an online intervention during inpatient or day-clinic psychotherapeutic treatment.

METHODS AND FINDINGS

In a naturalistic study, we investigated the transferability of the transdiagnostic psychodynamic online self-help program KEN-Online, which includes eight consecutive units. Between May 2017 and October 2018, patients who received inpatient or day-clinic psychotherapeutic treatment at the Department of Psychosomatic Medicine and Psychotherapy in the University Medical Center Mainz have been offered to use KEN-Online. Of the n = 749 patients who were admitted to the clinic, n = 239 patients (32%) registered for participation in KEN-Online. While 46.9% of the participants did not complete any unit (inactive participants), 53.1% completed at least the first unit (active participants). Age, number of diagnoses, and symptom severity were associated with (in)active participation. Adherence decreased over time resulting in only 17 participants (7.6%) who completed all units. None of the sociodemographic and medical characteristics proved to be significant predictors of adherence. Analyses of effectiveness showed a significant reduction of anxiety and depression in active participants in the course of participation, with higher improvements in participants that completed more than half of the units.

CONCLUSION

Adherence to the online self-help program KEN-Online was lower in the naturalistic setting than in a previous clinical trial, but was still associated with greater program effectiveness. Adherence-promoting measures are crucial to increase the effectiveness of such interventions in clinical settings.

Efficacy of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Meta-Analysis of Recent Literature

PURPOSE OF REVIEW

Effective treatment of anxiety-related disorders is crucial, considering the prevalence of such disorders and their association with poor psychosocial functioning. To evaluate the most recent evidence on the efficacy of cognitive behavioral therapy (CBT) for anxiety-related disorders in adults, we conducted a meta-analysis of randomized placebo-controlled trials published since 2017.

RECENT FINDINGS

Ten studies with a total of 1250 participants met the inclusion criteria. Seven of these studies examined PTSD. The findings demonstrated small placebo-controlled effects of CBT on target disorder symptoms (Hedges' g = 0.24, p < 0.05) and depression (Hedges' g = 0.15, p = n.s). When examining only PTSD studies, effects were reduced (Hedges' g = 0.14, p < 0.05). Heterogeneity in most analyses was very low, and no publication bias was found. Effect sizes from placebo-controlled trials from the past 5 years appear to be smaller than those in prior meta-analyses. The findings are largely driven by research on PTSD, with few placebo-controlled trials of other anxiety-related disorders published since 2017.

Evaluation of the Use of Digital Mental Health Platforms and Interventions: Scoping Review

BACKGROUND

The increasing use of digital mental health (DMH) platforms and digital mental health interventions (DMHIs) is hindered by uncertainty over effectiveness, quality and usability. There is a need to identify the types of available evidence in this domain.

AIM

This study is a scoping review identifying evaluation of the (1) DMH platform/s used; and (2) DMHI/s applied on the DMH platform/s.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guided the review process. Empirical studies that focused on evaluation of the use and application of DMH platforms were included from journal articles (published 2012-2022). A literature search was conducted using four electronic databases (Scopus, ScienceDirect, Sage and ACM Digital Library) and two search engines (PubMed and Google Scholar).

RESULTS

A total of 6874 nonduplicate records were identified, of which 144 were analyzed and 22 met the inclusion criteria. The review included general/unspecified mental health and/or suicidality indications (n = 9, 40.9%), followed by depression (n = 5, 22.7%), psychosis (n = 3, 13.6%), anxiety and depression (n = 2, 9.1%), as well as anxiety, depression and suicidality (n = 1, 4.5%), loneliness (n = 1, 4.5%), and addiction (n = 1, 4.5%). There were 11 qualitative studies (50%), 8 quantitative studies (36.4%), and 3 mixed-methods studies (n = 3, 13.6%). The results contained 11 studies that evaluated the DMH platform/s and 11 studies that evaluated the DMHI/s. The studies focused on feasibility, usability, engagement, acceptability and effectiveness. There was a small amount of significant evidence (1 in each 11), notably the (cost-)effectiveness of a DMHI with significant long-term impact on anxiety and depression in adults.

CONCLUSION

The empirical research demonstrates the feasibility of DMH platforms and DMHIs. To date, there is mostly heterogeneous, preliminary evidence for their effectiveness, quality and usability. However, a scalable DMHI reported effectiveness in treating adults' anxiety and depression. The scope of effectiveness may be widened through targeted strategies, for example by engaging independent young people.

Mapping User Engagement in Digital Psychotherapy: An Integrative Engagement Model (Preprint)

BACKGROUND

Digital mental health interventions, such as 2-way and asynchronous messaging therapy, are a growing part of the mental health care treatment ecosystem, yet little is known about how users engage with these interventions over the course of their treatment journeys. User engagement, or client behaviors and therapeutic relationships that facilitate positive treatment outcomes, is a necessary condition for the effectiveness of any digital treatment. Developing a better understanding of the factors that impact user engagement can impact the overall effectiveness of digital psychotherapy. Mapping the user experience in digital therapy may be facilitated by integrating theories from several fields. Specifically, health science's Health Action Process Approach and human-computer interaction's Lived Informatics Model may be usefully synthesized with relational constructs from psychotherapy process-outcome research to identify the determinants of engagement in digital messaging therapy.

OBJECTIVE

This study aims to capture insights into digital therapy users' engagement patterns through a qualitative analysis of focus group sessions. We aimed to synthesize emergent intrapersonal and relational determinants of engagement into an integrative framework of engagement in digital therapy.

METHODS

A total of 24 focus group participants were recruited to participate in 1 of 5 synchronous focus group sessions held between October and November 2021. Participant responses were coded by 2 researchers using thematic analysis.

RESULTS

Coders identified 10 relevant constructs and 24 subconstructs that can collectively account for users' engagement and experience trajectories in the context of digital therapy. Although users' engagement trajectories in digital therapy varied widely, they were principally informed by intrapsychic factors (eg, self-efficacy and outcome expectancy), interpersonal factors (eg, the therapeutic alliance and its rupture), and external factors (eg, treatment costs and social support). These constructs were organized into a proposed Integrative Engagement Model of Digital Psychotherapy. Notably, every participant in the focus groups indicated that their ability to connect with their therapist was among the most important factors that were considered in continuing or terminating treatment.

CONCLUSIONS

Engagement in messaging therapy may be usefully approached through an interdisciplinary lens, linking constructs from health science, human-computer interaction studies, and clinical science in an integrative engagement framework. Taken together, our results suggest that users may not view the digital psychotherapy platform itself as a treatment so much as a means of gaining access to a helping provider, that is, users did not see themselves as engaging with a platform but instead viewed their experience as a healing relationship. The findings of this study suggest that a better understanding of user engagement is crucial for enhancing the effectiveness of digital mental health interventions, and future research should continue to explore the underlying factors that contribute to engagement in digital mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04507360; https://clinicaltrials.gov/ct2/show/NCT04507360.

Das Beste aus zwei Welten: Eine systematische Übersicht zu Faktoren der Implementierung einer “Blended Therapy” (Gemischte Therapie) in der Psychotherapeutischen Routineversorgung

<b><i>Ziel:</i></b> Diese Arbeit gibt einen Überblick über bisherige wissenschaftliche Empfehlungen zur Implementierung der blended therapy, d.h. der Kombination von Therapien in Präsenz und via digitaler Medien. Die Empfehlungen um­fassen die Themen: (1) wahrgenommene Barrieren von Psychotherapeut*innen, (2) Format der blended therapy und (3) Indikationen für Patient*innen. In diesem Rahmen werden Faktoren aufgezeigt, die Akteur*innen im Gesundheitssystem als Orientierung dienen können, welche Determinanten bei der Implementierung in die Routineversorgung zu berücksichtigen sind. <b><i>Methodik:</i></b> Die systematische Suche erfolgte in den Datenbanken PsycArticles, PsycInfo, PSYNDEX und PubMed. <b><i>Ergebnisse:</i></b> Die Publikationen umfassen vier quantitative, neun qualitative sowie drei Mixed-Methods-Studien. Die bisherigen Arbeiten kommen zu dem Ergebnis, dass Psychotherapeut*innen frühzeitig in den Implementierungsprozess einbezogen und langfristige supportive Maßnahmen für die Umstrukturierung der bisherigen Arbeitsroutine geschaffen werden sollten. Das Format der blended therapy sollte nicht standardisiert angewandt, sondern vielmehr individuell an die Patient*innen angepasst werden. Hinsichtlich möglicher Indikationen werden verschiedene Einflussfaktoren der Patient*innen diskutiert, die bisher jedoch nur unzureichend untersucht wurden. <b><i>Diskussion:</i></b> Bisherige Studien weisen größtenteils homogene Charakteristika und Ergebnisse auf. Forschungslücken bestehen hinsichtlich der Frage, inwieweit sich die Ergebnisse auf andere Therapieschulen, Berufsgruppen und Störungsbilder übertragen lassen. <b><i>Schlussfolgerung:</i></b> Das Review veranschaulicht, dass es wichtiger Vorarbeit hinsichtlich der Anwendungsunterstützung für Psychotherapeut*innen sowie weiterer Forschungsaktivität bedarf, um die Implementierung von blended therapy im Sinne einer möglichen Verbesserung der psychotherapeutischen Versorgung voranzutreiben.

Impact of guidance on intervention adherence in computerised interventions for mental health problems: a meta-analysis

Web-based interventions are increasingly used for the prevention, treatment and aftercare of mental disorders. A crucial factor to the efficacy of such online programmes is adherence to the intervention content and procedure. It has been frequently suggested that adherence in web-based interventions is low and little is known about which factors influence adherence. To increase intervention uptake and completion, studies increasingly include interventions with some form of guidance. Guided interventions have been shown to have higher efficacy, however, evidence for the impact on adherence is limited and mixed. This meta-analysis explored the impact of human guidance on intervention completion in web-based mental health interventions. A total of 22 studies were included with interventions primarily targeting symptoms of depression and anxiety disorders. Results showed that guidance significantly increases the average amount of intervention completion [g = 0.29, 95% confidence interval (CI) 0.18-0.40] and the proportion of intervention completers [log odds ratio (OR) = 0.50, 95% CI 0.34-0.66] with small effects. On average, full completion rates were 12% higher in guided intervention groups. This meta-analysis demonstrated that guidance in web-based mental health interventions does increase adherence, but more research is required to better understand the specific mechanisms between guidance, adherence and outcomes.

COVID-19 related differences in the uptake and effects of internet-based cognitive behavioural therapy for symptoms of obsessive-compulsive disorder

BACKGROUND

The impacts of COVID-19 for people with obsessive-compulsive disorder (OCD) may be considerable. Online cognitive behavioural therapy (iCBT) programmes provide scalable access to psychological interventions, although the effectiveness of iCBT for OCD during COVID-19 has not been evaluated.

AIM

This study investigated the uptake and effectiveness of iCBT for OCD (both self- and clinician-guided courses) during the first 8 months of the pandemic in Australia (March to October 2020) and compared outcomes with the previous year.

METHOD

1,343 adults (824/1343 (61.4%) female, mean age 33.54 years, SD = 12.00) commenced iCBT for OCD (1061 during the pandemic and 282 in the year before) and completed measures of OCD (Dimensional Obsessive-Compulsive Scale) and depression (Patient Health Questionaire-9) symptom severity, psychological distress (Kessler-10), and disability (WHO Disability Assessment Schedule) pre- and post-treatment.

RESULTS

During COVID-19, there was a 522% increase in monthly course registrations compared with the previous year, with peak uptake observed between April and June 2020 (a 1191% increase compared with April to June 2019). OCD and depression symptom severity were similar for the COVID and pre-COVID groups, although COVID-19 participants were more likely to enrol in self-guided courses (versus clinician-guided). In both pre- and during-COVID groups, the OCD iCBT course was associated with medium effect size reductions in OCD (g = 0.65-0.68) and depression symptom severity (g = 0.56-0.65), medium to large reductions in psychological distress (g = 0.77-0.83) and small reductions in disability (g = 0.35-.50).

CONCLUSION

Results demonstrate the considerable uptake of online psychological services for those experiencing symptoms of OCD during COVID-19 and highlight the scalability of effective digital mental health services.

A Systematic Review of the Effectiveness, Content, and Usage Patterns of Mobile Mental Health Interventions on Smartphone Platforms for Anxiety Symptoms

"This systematic review aims to examine the content, usage pattern and efficacy of mobile mental health interventions in reducing anxiety symptoms. A search of 10 electronic databases returned 44 408 studies in total and 27 studies met the inclusion criteria, including 4460 participants in total. The rate of attrition was 27% (SD = 22) among the participants who initiated the app use. The rate of significant reductions in measures of anxiety symptoms was 87% from within-subjects pretest to posttest assessments, yet this rate dropped to 46% when compared to a waitlist/control group. A vast majority of the studies used cognitive and/or behavioral interventions (N = 26, 96%), a few studies included professional support (N = 11, 41%), a structured form of delivering the interventions (N = 8, 30%) or tailored it to users’ needs (N = 6, 22%). Few studies reported the actual time spent on the app per week (N = 4, M = 63.76, SD = 62.17). The mobile mental health interventions were effective in reducing anxiety symptoms, yet this effectiveness eroded compared to control groups. There is a need to develop consistent ways of reporting the usage patterns and testing evidence-based interventions other than cognitive behavioral treatments."

A tale of two countries: Increased uptake of digital mental health services during the COVID-19 pandemic in Australia and New Zealand

BACKGROUND

Digital mental health services (DMHS) provide highly accessible psychological supports and interventions that can supplement existing mental health services. Concerns about the mental health impact of the COVID-19 pandemic have been widespread and provide a unique impetus to examine the utility and responsivity of DMHS. This study examined the service utilisation and user characteristics of two DMHS (THIS WAY UP and Just a Thought) in Australia and New Zealand before and during the early pandemic period in these countries (March to June 2020).

METHODS

Service use indices (website visits, course registrations and prescriptions, clinician registrations) were compared across different time periods before (12, 6 and 3 months) and during the pandemic in Australia and New Zealand. The demographic and clinical characteristics of course registrants (anxiety and depression symptom severity and psychological distress) were also compared across the pre- and during-COVID periods.

RESULTS

Comparing pre-COVID to during-COVID time periods, we observed substantial increases across all service use indices in both DMHS (increases of >100% on the majority of service use indices). For example, in the 3 months prior to the pandemic, 2806 people registered for a THIS WAY UP course and 1907 people registered for a Just a Thought course, whereas 21,872 and 5442 registered for a THIS WAY UP and Just a Thought course, respectively, during the first 3 months of the COVID pandemic. Slight differences in the demographic and clinical profiles of course registrants were found between pre- and during-COVID time periods, with limited evidence of elevated anxiety and depression symptom severity in the COVID period.

CONCLUSIONS

Following the outbreak of COVID-19 in Australia and New Zealand, the volume of users accessing DMHS increased yet the demographic and clinical characteristics of course registrants remained stable. Results underscore how nimble and scalable DMHS can be during periods of high demand.