Selecting and describing control conditions in mobile health randomized controlled trials: a proposed typology

Effects of a single session low-threshold digital intervention for procrastination behaviors among university students (Focus): Findings from a randomized controlled trial

Introduction

Procrastination behaviors are common among university students, and have been found to be associated with stress, symptoms of depression, anxiety, and poorer academic performance. There is a need for interventions that can reach students at scale, and therefore this study aimed to estimate the effects of a single session low-threshold digital intervention (Focus) for procrastination behaviors among university students in Sweden.

Methods and analysis

A two-arm, parallel groups (1:1), single blind randomized controlled trial was conducted between February 8 to April 26, 2023. The study used email to invite university students across Sweden to participate in the trial. Both the intervention and the control group were invited to assess their current procrastination behaviors using the Pure Procrastination Scale (PPS). The intervention group immediately received feedback and behavior change advice by means of an interactive website, while the control group was shown their total PPS score without any further feedback. Students were included in the study if they scored 20 points or more on the PPS. Our primary outcome was procrastination behavior measured at 2 months post-randomization. Analyses were conducted using multilevel regression models estimated with Bayesian inference.

Results

A total of 2209 participants (intervention: 1109, control: 1100) were randomized. The average age of participants was 26.4 years (SD = 7.8) and 65 % were women (n = 1442). The mean PPS score at baseline was 35.6 points (of a maximum of 60). Primary outcome data were available for 45 % (n = 498) of the intervention group and 55 % (n = 601) of the control group. The evidence suggested no marked difference between groups regarding any of the outcomes, although there was weak evidence of lower physical activity in the intervention group. Qualitative findings from open-ended responses uncovered a variety of views on procrastination and perceived problems that may follow. Those not feeling supported by Focus explained having troubles adopting the advice given and converting their intentions into action without more continuous support.

Conclusions

Access to a single session of feedback and behavior change advice by means of an interactive website did not produce differential self-reported procrastination among university students who took the opportunity to self-assess their behaviors. The findings are limited by assessment reactivity due to screening at baseline and attrition to follow-up.

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).

Treating perfectionism via the Internet: a randomized controlled trial comparing cognitive behavior therapy to unified protocol

Perfectionism can be problematic when your self-worth is dependent on achievements and leads to inflexible standards, cognitive biases, and rigid behaviors. Cognitive behavior therapy for perfectionism is shown to be effective, including for targeting psychiatric symptoms and when delivered via the Internet (iCBT-P). However, few studies have compared it to an active comparator. The current study randomly assigned 138 participants seeking help for perfectionism to iCBT-P or Internet-based Unified Protocol (iUP). Both treatments provided guidance on demand from a therapist and were eight weeks in duration. The results indicated large within-group effects of Cohen's d 2.03 (iCBT) and 2.51 (iUP) on the Clinical Perfectionism Questionnaire at post-treatment, and maintained effects at 6- and 12-month follow-up, but no between-group difference (β = 0.02, SE = 1.04, p = .98). Secondary outcomes of depression, anxiety, quality of life, self-compassion, procrastination, and stress ranged from small to large, with no differences between the conditions. Both treatments were deemed credible, relevant, of high quality, and well-adhered by the participants. Further research needs to be conducted, but the findings could indicate a lack of specificity, perhaps suggesting there is no need to differentiate between different treatments that are transdiagnostic in nature.

Treating comorbid insomnia in patients enrolled in therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy for anxiety and depression: A randomized controlled trial

Transdiagnostic Internet-delivered cognitive behaviour therapy (ICBT) for patients experiencing anxiety and depression can produce large improvements in symptoms. Comorbid insomnia is common among individuals seeking treatment for anxiety and depression, yet transdiagnostic ICBT rarely targets insomnia and many ICBT patients report that symptoms of insomnia remain after treatment. This trial explored the impact of including a brief intervention for insomnia alongside an existing transdiagnostic ICBT course that included brief weekly therapist assistance. Patients were randomly assigned to receive either the Standard transdiagnostic (n = 75) or a Sleep-Enhanced course (n = 142), which included information on sleep restriction and stimulus control. Intent-to-treat analyses using generalized estimating equation (GEE) showed significant, large reductions in all primary outcomes (insomnia: d = 0.96, 95 % CI [0.68, 1.24]; depression: d = 1.04, 95 % CI [0.76, 1.33]; and anxiety: d = 1.23, 95 % CI [0.94, 1.52]) from pre-treatment to post-treatment, with changes maintained at 3-months. Patients assigned to the Sleep-Enhanced course reported larger reductions in insomnia than patients in the Standard transdiagnostic course (Cohen's d = 0.31, 95 % CI [0.034, 0.60]) at post-treatment but no significant between-group differences in any of the primary outcomes were found at follow-up. Patient-reported adherence to sleep restriction guidelines (p = .03), but not stimulus control instructions (p = .84) was associated with greater reductions in insomnia symptoms during the course. Overall, patients who received the Sleep-Enhanced course were satisfied with the materials and most patients reported making sleep behaviour changes. The trial results demonstrate that including a brief intervention targeting insomnia can be beneficial for many patients who enroll in ICBT primarily for symptoms related to anxiety and depression.

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Efficacy of a smartphone-based Cognitive Bias Modification program for emotion regulation: A randomized-controlled crossover trial

Previous research has identified maladaptive emotion regulation as a key factor in psychopathology. Thus, addressing emotion regulation via scalable, low-threshold digital interventions - such as smartphone-based Cognitive Bias Modification (CBM) - holds important therapeutic potential. Using a randomized-controlled crossover trial, we tested the efficacy of an integrated CBM module within the Affect Regulation Training (ART, i.e., CBM-ART) that targeted emotion regulation through elements of appraisal-based and approach avoidance training. Undergraduate students reporting elevated stress were randomized to a one-week active intervention (Mindgames; including psychoeducation, a quiz, and CBM-ART; n = 40), active control training (Emo Shape; including placebo psychoeducation, a quiz, and a placebo swiping task; n = 36) or waitlist (n = 25). Before and after the intervention, we assessed emotion regulation, interpretation bias, stress and depression. We further tested post-training stress reactivity using an anagram task. Results indicated that the active intervention improved negative (OR = 0.35) and positive (OR = 2.40) interpretation biases and symptom measures (d = 0.52-0.87). However, active control training showed attenuated concurrent pre-post changes on interpretation biases (i.e., OR = 0.53 for negative, and OR = 1.49 for positive interpretations) and symptom measures (d = 0.26-0.91). The active intervention was rated positively in terms of acceptability and usability. These findings provide initial evidence for the efficacy and acceptability of an integrated app-based CBM intervention for emotion regulation in reducing interpretation biases and psychopathological symptoms, including stress. However, future studies should disentangle specific mechanisms underlying interventional effects.

Effectiveness of Online and Remote Interventions for Mental Health in Children, Adolescents, and Young Adults After the Onset of the COVID-19 Pandemic: Systematic Review and Meta-Analysis

BACKGROUND

The prevalence of mental illness increased in children, adolescents, and young adults during the COVID-19 pandemic, while at the same time, access to treatment facilities has been restricted, resulting in a need for the quick implementation of remote or online interventions.

OBJECTIVE

This study aimed to give an overview of randomized controlled studies examining remote or online interventions for mental health in children, adolescents, and young adults and to explore the overall effectiveness of these interventions regarding different symptoms.

METHODS

A systematic literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, PsycInfo, Psyndex, Embase, and Google Scholar. A meta-analysis was conducted using a random effects model to calculate overall effect sizes for interventions using standardized mean differences (SMDs) for postintervention scores.

RESULTS

We identified 17 articles with 8732 participants in the final sample, and 13 were included in the quantitative analysis. The studies examined different digital interventions for several outcomes, showing better outcomes than the control in some studies. Meta-analyses revealed significant medium overall effects for anxiety (SMD=0.44, 95% CI 0.20 to 0.67) and social functioning (SMD=0.42, 95% CI -0.68 to -0.17) and a large significant effect for depression (SMD=1.31, 95% CI 0.34 to 2.95). In contrast, no significant overall treatment effects for well-being, psychological distress, disordered eating, and COVID-19-related symptoms were found.

CONCLUSIONS

The qualitative and quantitative analyses of the included studies show promising results regarding the effectiveness of online interventions, especially for symptoms of anxiety and depression and for training of social functioning. However, the effectiveness needs to be further investigated for other groups of symptoms in the future. All in all, more research with high-quality studies is required.

Therapist-guided, Internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder: A feasibility trial with long-term follow-up

Body dysmorphic disorder (BDD) is a prevalent and impairing psychiatric condition that typically debuts in adolescence and is associated with risky behaviours. The disorder can be effectively treated with cognitive behaviour therapy (CBT). However, CBT for BDD is seldom available primarily due to a shortage of trained therapists. Internet-delivered CBT (ICBT) can be a way to increase treatment availability. The aim of this feasibility trial was to evaluate the feasibility, safety, and preliminary efficacy of a CBT protocol for adolescents with BDD, adapted to be delivered over the Internet with minimal therapist support. A total of 20 participants (12-17-year-olds) meeting criteria for BDD were recruited nationally to a specialist outpatient clinic in Stockholm, Sweden. One participant withdrew consent and their data could not be analysed. Nineteen participants were offered 12 modules of therapist-guided ICBT for BDD and were followed up to 12 months post-treatment. Preliminary efficacy was measured at the a priori primary endpoint (3-month follow-up) and at the 12-month follow-up with the clinician-rated Yale-Brown Obsessive Compulsive Scale Modified for BDD for Adolescents. The treatment was rated as both credible and satisfactory and was associated with a large and statistically significant reduction in BDD symptom severity (d = 2.94). The proportion of participants classified as responders at the primary endpoint was 73.7%, and the proportion of full or partial remitters was 63.2%. The average therapist support time was 8 min per participant per week. Treatment gains continued to accrue up to the 12-month follow-up. Two participants attempted suicide and another two reported non-suicidal self-injuries during the study period. ICBT with minimal therapist support is a feasible, potentially efficacious, and durable treatment for adolescents with BDD. Risky behaviours typical of this patient group should be carefully monitored during treatment.

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

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