Integrating internet CBT into clinical practice: a practical guide for clinicians

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.

Acceptability of internet-delivered cognitive behavioural therapy for adults with symptoms of obsessive-compulsive disorder: A meta-analysis

OBJECTIVES

Obsessive-compulsive disorder (OCD) is a chronic mental health disorder. Internet-delivered cognitive behaviour therapy (ICBT) is demonstrated to be effective for OCD; however little is known about the acceptability of the treatment. Therefore the aim of this study was to examine the acceptability of ICBT for adults with OCD symptoms using a meta-analytic approach.

METHOD

Seventeen studies (N = 1661; Mage range = 28-41 years; 58%-93% female) were included in this analysis.

RESULTS

The random effects pooled estimates indicated that 16.3% (95% CI: 9.8%-25.7%) of participants did not commence the treatment once they were enrolled in the study, 27.6% (95% CI: 19.0%-38.2%) did not complete the treatment, and 27.0% (95% CI: 18.2%-38.0%) did not complete the post-treatment questionnaires of the study. The mean score on the Client Satisfaction Questionnaire ranged from 22.4 to 26.5. Overall, pooled estimates indicated that 81.6% (95% CI: 76.1%-86.0%) of participants were satisfied with the ICBT intervention and 84.7% (95% CI: 72.8%-92.0%) indicated that they would recommend the treatment to a friend. Some of the acceptability moderator analyses indicated that self-guided ICBT interventions had lower levels of acceptability compared with clinician-guided interventions. However, given low power, these results should be considered preliminary.

CONCLUSIONS

This study has important implications in the dissemination of ICBT for OCD.

Chronic health conditions and disability are prevalent among community users of a digital mental health service: a scoping survey

Objectives: Digital interventions can offer accessible and scalable treatment for chronic conditions, though often focus separately on physical or mental health. People accessing digital health services may live with multiple conditions or experience overlapping symptoms. This study aimed to describe the breadth and characteristics of chronic health conditions and self-reported disability among routine users of a digital mental health service, and to examine related motivations to engage with digital mental health interventions.

Methods: A cross-sectional survey of adults registered with a digital mental health service in the Australian community (THIS WAY UP) was conducted. Participant demography, chronic health conditions, self-reported disability and motivations for accessing digital treatment were collected and analyzed descriptively.

Results: 366 participants responded (77% female, mean age 50 ± 15 years). 71.6% of participants (242/338) reported ≥1 chronic health condition and one-third reported multimorbidity (112/338, 33.1%). Chronic pain, musculoskeletal and connective tissue disorders were most common. 26.9% of respondents (90/334) reported a disability, most commonly physical disabilities. 95% of those with chronic conditions reported negative mental health effects and 46% reported heightened interest in digital mental health treatments because of their condition. Primary motivations for digital service use were receiving a recommendation from a health professional and service accessibility.

Discussion: People who access digital mental health services in routine care report high rates of heterogenous chronic illness and related disability. There is interest in accessible digital treatments to support mental health at scale among people who live with varied chronic conditions and disabilities.

Online Intervention Targeting Postnatal Depression and Anxiety in Chilean First-Time Mothers: Feasibility Trial

OBJECTIVE

Internet-based interventions may positively impact maternal symptoms of postnatal depression and anxiety. This study assessed the feasibility, acceptability, perceived usefulness, and preliminary effectiveness of an m-Health version of "What Were We Thinking?" (m-WWWT).

METHODS

A mixed-methods with a 2-arm randomized parallel design was used. From a total of 477 women, 157 met the inclusion criteria. 128 first-time mothers of full-term infants, aged 4-10 weeks, who received health care at primary public health centers in Chile, were randomly assigned to the experimental (EG, n = 65) or control (CG, n = 63) groups; data of 104 of them (53 and 51, respectively) was analyzed. We used percentages and rates to measure feasibility outcomes and mixed analysis of variance (ANOVA) and latent class analyses (LCA) to assess preliminary effectiveness. Participants completed questionnaires on mental health, social support, and maternal self-efficacy upon recruitment and 3 months after completing the intervention. For the qualitative component, 12 women from the EG were interviewed.

RESULTS

Quantitative results show good feasibility outcomes, such as high recruitment (82%), low attrition (EG = 12% and CG = 17%), and high follow-up (EG = 97% and CG = 91%) rates. Qualitative results indicate high acceptability and perceived usefulness of m-WWWT. Mixed ANOVA did not show significant differences between the groups (all p >.05). However, multinomial regression analysis in LCA showed that women with low baseline symptoms of depression and anxiety benefit from the intervention (B = 0.43, 95% confidence interval 1.09-2.16).

CONCLUSION

m-WWWT is feasible to be implemented in Chile; future studies are needed to assess the intervention's effectiveness.

Identifying and developing strategies for implementation of a guided internet- and mobile-based infant sleep intervention in well-baby and community mental health clinics using group concept mapping

BACKGROUND

This study aimed to identify strategies for the implementation of a guided internet- and mobile-based intervention (IMI) for infant sleep problems ("Sleep Well, Little Sweetheart") in well-baby and community mental health clinics.

STUDY DESIGN

We used group concept mapping, a two-phased mixed methods approach, conducted as a two-day workshop in each clinic. We recruited 20 participants from four clinics and collected sorting and rating data for implementation strategies based on the Expert Recommendations for Implementing Change taxonomy and brainstorming sessions. Data were analyzed using descriptive statistics, multidimensional scaling, and hierarchical cluster analysis to create cluster maps, laddergrams, and Go-Zone graphs. Participants were presented with the results and discussed and interpreted the findings at each of the clinics in spring 2022.

RESULTS

Participants identified 10 clusters of strategies, of which Training, Embedding and Coherence, User Involvement and Participation, and Clinician Support and Implementation Counseling were rated as most important and feasible. Economy and Funding and Interactive and Interdisciplinary Collaboration were rated significantly lower on importance and feasibility compared to many of the clusters (all ps < 0.05). There was a correlation between the importance and feasibility ratings (r =.62, p =.004).

CONCLUSIONS

The use of group concept mapping made it possible to efficiently examine well-baby and community clinics' perspectives on complex issues, and to acquire specific knowledge to allow for the planning and prioritization of strategies for implementation. These results suggest areas of priority for the implementation of IMIs related to infant sleep problems.

TRIAL REGISTRATION

The study was pre-registered at Open Science Framework ( www.osf.io/emct8 ).

Hurdles and potentials when implementing internet-delivered Acceptance and commitment therapy for chronic pain: a retrospective appraisal using the Quality implementation framework

OBJECTIVES

Internet-delivered psychological interventions can be regarded as evidence-based practices and have been implemented in psychiatric and somatic care at primary and specialist levels. However, challenges as low adherence and poor routinization, have arisen during attempts to implement internet-delivered interventions in chronic pain settings. Internet-delivered Acceptance and Commitment Therapy (IACT) has been found to be helpful for chronic pain patients and might aid in developing pain rehabilitation services. However, the integration of IACT into standard health care has not yet been described from an implementation science perspective. The aim of this hybrid 1 effectiveness-implementation study was to evaluate the process of implementing IACT in a pain rehabilitation setting, to guide future implementation initiatives.

METHODS

In this retrospective study we described actions taken during an implementation initiative, in which IACT was delivered as part of an interdisciplinary pain rehabilitation program (IPRP) at a specialist level clinic. All documents relevant to the study were reviewed and coded using the Quality Improvement Framework (QIF), focusing on adoption, appropriateness and sustainability.

RESULTS

The QIF-analysis of implementation actions resulted in two categories: facilitators and challenges for implementation. Sustainability may be facilitated by sensitivity to the changing needs of a clinical setting and challenged by unfitting capacity building. Appropriateness might be challenged by an insufficient needs assessment and facilitated by aligning routines for communication with the clinic's existing infrastructure. Adoption may be facilitated by staff key champions and an ability to adapt to occurring hurdles. Possible influential factors, hypotheses and key process challenges are presented in a logic model to guide future initiatives.

CONCLUSIONS

Sustainable implementation may depend on both the continuity of facilitating implementation actions and flexibility to the changing needs and interests of patients, caregivers and organization. We conclude that the use of theories, models and frameworks (TMF) as well as a logic model may ease design, planning and evaluation of an implementation process. Lastly, we suggest that IACT may be appropriate for IPRP when given before or after IPRP, focusing on psychiatric comorbidities.

Therapeutic games to reduce anxiety and depression in young people: A systematic review and exploratory meta-analysis of their use and effectiveness

OBJECTIVE

The development of serious games for mental wellbeing is a topic of growing interest. The increase in acceptance of games as a mainstream entertainment medium combined with the immersive qualities of games provides opportunities for meaningful support and intervention in mental wellbeing.

METHOD

We conducted a systematic review and exploratory meta-analysis to examine if aspects of the interventions influenced outcomes as measured via overall effect sizes. We employed a multilevel meta-analytic approach to accommodate the interdependency of effect sizes (18 effect sizes from 14 studies, with 2027 participants).

RESULTS

Overall, the main effect for gaming interventions on any outcome variable was small to medium sized, d = .35 (confidence interval [.23, 47], p < .001). Results revealed that the only significant moderator was the nature of the intervention. Specifically, only interventions that included a rational emotional behavioural focus significantly predicted an improvement in depression and/or anxiety in participants.

CONCLUSION

The findings reveal promising effects for therapeutic games for mental health, but replications are needed, alongside the addressing of methodological and procedural concerns.

Managing Rumination and worry: A randomised controlled trial of an internet intervention targeting repetitive negative thinking delivered with and without clinician guidance

BACKGROUND

Rumination and worry, forms of repetitive negative thinking (RNT), are implicated in the onset, maintenance, severity, and relapse risk of depression and anxiety disorders. This randomised controlled trial evaluated an internet intervention targeting both rumination and worry in adults compared to treatment-as-usual (TAU) and compared treatment effects and adherence when delivered with and without clinician guidance.

METHODS

Adults (N = 137) with elevated RNT were randomly allocated to a 3-lesson clinician guided (n = 45) or self-help (n = 47) online program delivered over 6 weeks, or a TAU control group which waited 18 weeks to receive the program (n = 45). The clinician guided group received semi-structured phone support after each lesson. All three groups continued any pre-trial TAU. RNT, anxiety, depression, and psychological distress were assessed at baseline, post-treatment (week 7), and 3-month follow-up.

RESULTS

Intention-to-treat linear mixed models showed that participants in the self-help and clinician guided groups had significantly lower RNT, anxiety, depression, and distress at post-treatment and 3-month follow-up compared to TAU. Treatment effects were significantly larger in the clinician guided group compared to self-help (between-group gs = 0.41-0.97). No significant between-group differences were found in adherence/program completion (guided: 76%; self-guided: 79%) or treatment satisfaction (1-5 scale: guided: M = 4.17, SD = 1.20; self-guided: M = 3.89, SD = 0.93). Total time spent on clinician guidance was M = 48.64 min (SD = 21.28).

CONCLUSION

This brief online intervention for RNT is acceptable and efficacious in reducing RNT, anxiety, depression, and distress in both clinician guided and self-help formats. The program appeared most effective when delivered with clinician guidance. Larger definitive trials comparing guided and self-guided programs are needed. Australian and New Zealand Clinical Trials Registration number: ACTRN12620000959976.

Efficacy of a Brief Blended Cognitive Behavioral Therapy Program for the Treatment of Depression and Anxiety in University Students: Uncontrolled Intervention Study

BACKGROUND

Blended cognitive behavioral therapy (bCBT)-the combination of cognitive behavioral therapy and digital mental health applications-has been increasingly used to treat depression and anxiety disorders. As a resource-efficient treatment approach, bCBT appears promising for addressing the growing need for mental health care services, for example, as an early intervention before the chronification of symptoms. However, further research on the efficacy and feasibility of integrated bCBT interventions is needed.

OBJECTIVE

This study aimed to evaluate the efficacy of a novel bCBT program comprising short (25 min), weekly face-to-face therapy sessions combined with a smartphone-based digital health app for treating mild to moderate symptoms of depression or anxiety.

METHODS

This prospective uncontrolled trial comprised 2 measurement points (before and after treatment) and 2 intervention groups. We recruited university students with mild to moderate symptoms of depression or anxiety. On the basis of the primary symptoms, participants were assigned to either a depression intervention group (n=67 completers) or an anxiety intervention group (n=33 completers). Participants in each group received 6 weekly individual psychotherapy sessions via videoconference and completed modules tailored to their respective symptoms in the smartphone-based digital health app.

RESULTS

The depression group displayed medium to large improvements in the symptoms of depression (Cohen d=-0.70 to -0.90; P<.001). The anxiety group experienced significant improvements in the symptoms of generalized anxiety assessed with the Generalized Anxiety Disorder-7 scale with a large effect size (Cohen d=-0.80; P<.001) but not in symptoms of anxiety assessed with the Beck Anxiety Inventory (Cohen d=-0.35; P=.06). In addition, both groups experienced significant improvements in their perceived self-efficacy (Cohen d=0.50; P<.001 in the depression group and Cohen d=0.71; P<.001 in the anxiety group) and quality of life related to psychological health (Cohen d=0.87; P<.001 in the depression group and Cohen d=0.40; P=.03 in the anxiety group). Work and social adjustment of patients improved significantly in the depression group (Cohen d=-0.49; P<.001) but not in the anxiety group (Cohen d=-0.06; P=.72). Patients' mental health literacy improved in the anxiety group (Cohen d=0.45; P=.02) but not in the depression group (Cohen d=0.21; P=.10). Patient satisfaction with the bCBT program and ratings of the usability of the digital app were high in both treatment groups.

CONCLUSIONS

This study provides preliminary evidence for the feasibility and efficacy of a novel brief bCBT intervention. The intervention effects were generalized across a broad spectrum of patient-reported outcomes. Hence, the newly developed bCBT intervention appears promising for treating mild to moderate depression and anxiety in young adults.

Integrating digital interventions with clinical practice in youth mental health services

OBJECTIVE

Integrating digital technologies with clinical practice promises to improve access and enhance care in the context of high service demand and constrained capacity.

METHOD

We outline the emerging research in the integration of digital tools in clinical care, known as blended care, and provide case examples of mental health technology platforms currently in use, summarise findings regarding novel technologies such as virtual reality, and outline real-world implementation challenges and potential solutions.

RESULTS

Recent evidence shows that blended care approaches are clinically effective and improve service efficiency. Youth-specific technologies such as moderated online social therapy (MOST) are achieving a range of positive clinical and functional outcomes, while emerging technologies like virtual reality have strong evidence in anxiety disorder, and accumulating evidence in psychotic conditions. Implementation science frameworks show promise in helping overcome the common challenges faced in real-world adoption and ongoing use.

CONCLUSION

The integrated, blended use of digital mental health technologies with face-to-face clinical care has the potential to improve care quality for young people while helping overcome the growing challenges faced by youth mental health service providers.

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.