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Omylinska Thurston J, Aithal S, Liverpool S, Clark R, Moula Z, Wood J, Viliardos L, Rodríguez-Dorans E, Farish-Edwards F, Parsons A, Eisenstadt M, Bull M, Dubrow-Marshall L, Thurston S, Karkou V. Digital Psychotherapies for Adults Experiencing Depressive Symptoms: Systematic Review and Meta-Analysis. JMIR Ment Health 2024; 11:e55500. [PMID: 39348177 DOI: 10.2196/55500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND Depression affects 5% of adults and it is a major cause of disability worldwide. Digital psychotherapies offer an accessible solution addressing this issue. This systematic review examines a spectrum of digital psychotherapies for depression, considering both their effectiveness and user perspectives. OBJECTIVE This review focuses on identifying (1) the most common types of digital psychotherapies, (2) clients' and practitioners' perspectives on helpful and unhelpful aspects, and (3) the effectiveness of digital psychotherapies for adults with depression. METHODS A mixed methods protocol was developed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search strategy used the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework covering 2010 to 2024 and 7 databases were searched. Overall, 13 authors extracted data, and all aspects of the review were checked by >1 reviewer to minimize biases. Quality appraisal was conducted for all studies. The clients' and therapists' perceptions on helpful and unhelpful factors were identified using qualitative narrative synthesis. Meta-analyses of depression outcomes were conducted using the standardized mean difference (calculated as Hedges g) of the postintervention change between digital psychotherapy and control groups. RESULTS Of 3303 initial records, 186 records (5.63%; 160 studies) were included in the review. Quantitative studies (131/160, 81.8%) with a randomized controlled trial design (88/160, 55%) were most common. The overall sample size included 70,720 participants (female: n=51,677, 73.07%; male: n=16,779, 23.73%). Digital interventions included "stand-alone" or non-human contact interventions (58/160, 36.2%), "human contact" interventions (11/160, 6.8%), and "blended" including stand-alone and human contact interventions (91/160, 56.8%). What clients and practitioners perceived as helpful in digital interventions included support with motivation and accessibility, explanation of task reminders, resources, and learning skills to manage symptoms. What was perceived as unhelpful included problems with usability and a lack of direction or explanation. A total of 80 studies with 16,072 participants were included in the meta-analysis, revealing a moderate to large effect in favor of digital psychotherapies for depression (Hedges g=-0.61, 95% CI -0.75 to -0.47; Z=-8.58; P<.001). Subgroup analyses of the studies with different intervention delivery formats and session frequency did not have a statistically significant effect on the results (P=.48 and P=.97, respectively). However, blended approaches revealed a large effect size (Hedges g=-0.793), while interventions involving human contact (Hedges g=-0.42) or no human contact (Hedges g=-0.40) had slightly smaller effect sizes. CONCLUSIONS Digital interventions for depression were found to be effective regardless of format and frequency. Blended interventions have larger effect size than those involving human contact or no human contact. Digital interventions were helpful especially for diverse ethnic groups and young women. Future research should focus on understanding the sources of heterogeneity based on intervention and population characteristics. TRIAL REGISTRATION PROSPERO CRD42021238462; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=238462.
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Affiliation(s)
| | - Supritha Aithal
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Shaun Liverpool
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Rebecca Clark
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Zoe Moula
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - January Wood
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Laura Viliardos
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | | | - Fleur Farish-Edwards
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
| | - Ailsa Parsons
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Mia Eisenstadt
- Evidence Based Practice Unit, University College London, London, United Kingdom
| | - Marcus Bull
- Faculty of Life Sciences and Education, University of South Wales, Newport, United Kingdom
| | | | - Scott Thurston
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Vicky Karkou
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
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Terhorst Y, Kaiser T, Brakemeier EL, Moshe I, Philippi P, Cuijpers P, Baumeister H, Sander LB. Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2423241. [PMID: 39023887 PMCID: PMC11258589 DOI: 10.1001/jamanetworkopen.2024.23241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024] Open
Abstract
Importance While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary. Objective To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness. Data Sources A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials. Study Selection Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design. Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted. Main Outcomes and Measures Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs. Results The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46). Conclusions and Relevance In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.
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Affiliation(s)
- Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany
- Department of Psychology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tim Kaiser
- Methods and Evaluation/Quality Assurance, Freie Universität Berlin, Berlin, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, University Greifswald, Greifswald, Germany
| | - Isaac Moshe
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paula Philippi
- Department of Clinical Child and Adolescent Psychology and Psychotherapy, Bergische Universität Wuppertal, Wuppertal, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro-, and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany
| | - Lasse Bosse Sander
- Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Gervind E, Salem MB, Svanborg C, Nyström ME, Lilja JL, Kaldo V, Weineland S. The influence of organizational models on the implementation of internet-based cognitive behavior therapy in primary care: A mixed methods study using the RE-AIM framework. Internet Interv 2024; 35:100698. [PMID: 38174208 PMCID: PMC10761770 DOI: 10.1016/j.invent.2023.100698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Background Internet-Based Cognitive Behavioral Therapy (iCBT) holds great potential in addressing mental health issues, yet its real-world implementation poses significant challenges. While prior research has predominantly focused on centralized care models, this study explores the implementation of iCBT in the context of decentralized organizational structures within the Swedish primary care setting, where all interventions traditionally are delivered at local Primary Care Centers (PCCs). Aim This study aims to enhance our understanding of iCBT implementation in primary care and assess the impact of organizational models on the implementation's outcome using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Method A mixed-methods research design was employed to identify the factors influencing iCBT implementation across different levels, involving patients, therapists and managers. Data spanning two years was collected and analyzed through thematic analysis and statistical tests. The study encompassed 104 primary care centers, with patient data (n = 1979) sourced from the Swedish National Quality Register for Internet-Based Psychological Treatment (SibeR). Additionally, 53 iCBT therapists and 50 PCC managers completed the Normalization Measure Development Questionnaire, and 15 leaders participated in interviews. Results Our investigation identified two implementation approaches, one concentrated and one decentralized. Implementation effectiveness was evident through adherence rates suggesting that iCBT is a promising approach for treating mental ill-health in primary care, although challenges were observed concerning patient assessment and therapist drift towards unstructured treatment. Mandatory implementation, along with managerial and organizational support, positively impacted adoption. Results vary in terms of adherence to established protocols, with therapists working in concentrated model showing a significantly higher percentage of registration in the quality register SibeR (X2 (1, N = 2973) = 430.5774, p = 0.001). They also showed significantly higher means in cognitive participation (Z = -2.179, p = 0.029) and in reflective monitoring (Z = -2.548, p = 0.011). Discussion Overall, the study results demonstrate that iCBT, as a complex and qualitatively different intervention from traditional psychological treatment, can be widely implemented in primary care settings. The study's key finding highlights the substantial advantages of the concentrated organizational model. This model has strengths in sustainability, encourages reflective monitoring among therapists, the use of quality registers, and enforces established protocols. Conclusion In conclusion, this study significantly contributes to the understanding of the practical aspects associated with the implementation of complex internet interventions, particularly in the context of internet-based cognitive-behavioral therapy (iCBT). The study highlights that effective iCBT integration into primary care requires a multifaceted approach, taking into account organizational models, robust support structures, and a commitment to maintaining quality standards. By emphasizing these factors, our research aims to provide actionable insights that can enhance the practicability and real-world applicability of implementing iCBT in primary care settings.
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Affiliation(s)
- Elisabet Gervind
- Research, Development, Education and Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | | | - Cecilia Svanborg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Monica E. Nyström
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Josefine L. Lilja
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Viktor Kaldo
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Sandra Weineland
- Research, Development, Education and Innovation, Primary Health Care, Region Västra Götaland, Sweden
- Närhälsan, Region Västra Götaland, Sweden
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
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De Jesús-Romero R, Holder-Dixon AR, Buss JF, Lorenzo-Luaces L. Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review. J Med Internet Res 2024; 26:e50780. [PMID: 38300699 PMCID: PMC10870215 DOI: 10.2196/50780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/05/2023] [Accepted: 11/16/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature. OBJECTIVE Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence. METHODS Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures. RESULTS A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics. CONCLUSIONS It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions.
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Affiliation(s)
- Robinson De Jesús-Romero
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
| | - Amani R Holder-Dixon
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - John F Buss
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
| | - Lorenzo Lorenzo-Luaces
- Department of Psychological and Brain Sciences, Indiana University - Bloomington, Bloomington, IN, United States
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Vernmark K, Buhrman M, Carlbring P, Hedman-Lagerlöf E, Kaldo V, Andersson G. From research to routine care: A historical review of internet-based cognitive behavioral therapy for adult mental health problems in Sweden. Digit Health 2024; 10:20552076241287059. [PMID: 39381804 PMCID: PMC11459524 DOI: 10.1177/20552076241287059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 09/10/2024] [Indexed: 10/10/2024] Open
Abstract
This narrative historical review examines the development of internet-based cognitive behavioral therapy (ICBT) in Sweden, describing its progression within both academic and routine care settings. The review encompasses key publications, significant scientific findings, and contextual factors in real-world settings. Over 25 years ago, Sweden emerged as a pioneering force in internet-delivered treatment research for mental health. Since then, Swedish universities, in collaboration with research partners, have produced substantial research demonstrating the efficacy of ICBT across various psychological problems, including social anxiety disorder, panic disorder, generalized anxiety disorder, and depression. Although research conducted in clinical settings has been less frequent than in academic contexts, it has confirmed the effectiveness of therapist-supported ICBT programs for mild-to-moderate mental health problems in routine care. Early on, ICBT was provided as an option for patients at both the primary care level and in specialized clinics, using treatment programs developed by both public and private providers. The development of a national platform for delivering internet-based treatment and the use of procurement in selecting ICBT programs and providers are factors that have shaped the current routine care landscape. However, gaps persist in understanding how to optimize the integration of digital treatment in routine care, warranting further research and the use of specific implementation frameworks and outcomes. This historical perspective on the research and delivery of ICBT in Sweden over two decades offers insights for the international community into the development and broad dissemination of a specific digital mental health intervention within a national context.
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Affiliation(s)
- Kristofer Vernmark
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Moncia Buhrman
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | | | - Viktor Kaldo
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Wang M, Chen H, Yang F, Xu X, Li J. Effects of digital psychotherapy for depression and anxiety: A systematic review and bayesian network meta-analysis. J Affect Disord 2023; 338:569-580. [PMID: 37392941 DOI: 10.1016/j.jad.2023.06.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of digital psychotherapies for depression and anxiety. We conducted a systematic review and network meta-analyses (NMA) to make comparisons of digital psychotherapies. METHODS A bayesian NMA was conducted in this study. The databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and CINAL were searched for all eligible randomized controlled trials (RCTs) published from Jan 1, 2012 to Oct 1, 2022. We used the Cochrane Collaboration's Risk of bias tool for quality assessment. The primary outcomes were set as a standardized mean difference model in efficacy to describe continuous outcomes. We used STATA and WinBUGS to conduct a bayesian network meta-analysis of all interventions based on a random-effects model. This study was registered with PROSPERO, number CRD42022374558. RESULTS From the retrieved 16,750 publications, we included 72 RCTs (13,096 participants) with the overall medium quality and above. In terms of depression scale, cognitive behavioral therapy (CBT) was more effective than TAU (SMDs 0.53) and NT (SMDs 0.98). In terms of anxiety scale, CBT (SMDs 0.68; SMDs 0.72) and exercise therapy (ERT) (SMDs 1.01; SMDs 1.05) were more effective than TAU and NT. LIMITATIONS Uneven quality of literature, simple network, and subjective judgment. CONCLUSION Based on NMA results, we suggest that CBT, which is the most commonly used digital technology, should be preferred among digital psychotherapy for relieving depression and anxiety symptoms. Digital exercise therapy is an effective strategy to relieve some anxiety problems in the context of COVID-19.
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Affiliation(s)
- Min Wang
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100020, China
| | - Haoran Chen
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100020, China
| | - Fengchun Yang
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100020, China
| | - Xiaowei Xu
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100020, China
| | - Jiao Li
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100020, China.
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Beno A, Bertilsson M, Holmgren K, Glise K, Pousette A, Segerfelt K, Björk L. Does employer involvement in primary health care enhance return to work for patients with stress-related mental disorders? a cluster randomized controlled trial. BMC PRIMARY CARE 2023; 24:195. [PMID: 37730561 PMCID: PMC10512560 DOI: 10.1186/s12875-023-02151-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Stress-related disorders have become a major challenge for society and are associated with rising levels of sick leave. The provision of support to facilitate the return to work (RTW) for this patient group is of great importance. The aim of the present study was to evaluate whether a new systematic procedure with collaboration between general practitioners (GPs), rehabilitation coordinators (RCs) and employers could reduce sick leave days for this patient group. METHOD Employed patients with stress-related diagnoses seeking care at primary health care centres (PHCCs) were included in either the intervention group (n = 54), following the systematic intervention procedure, or the control group (n = 58), receiving treatment as usual (TAU). The intervention included a) a training day for participant GPs and RCs, b) a standardised procedure for GPs and RCs to follow after training, c) the opportunity to receive clinical advice from specialist physicians in the research group. Outcome measures for RTW were sick leave days. RESULTS The median number of registered gross sick leave days was lower for the control group at six, 12 and 24 months after inclusion, but the difference was not statistically significant. The control group had significantly fewer net sick leave days at three months (p = 0.03) at six months (p = 0.00) and at 12-months follow-up (p = 0.01). At 24 months, this difference was no longer significant. CONCLUSIONS The PRIMA intervention, which applied a standardized procedure for employer involvement in the rehabilitation process for patients with stress-related disorders, actually increased time to RTW compared to TAU. However, at 24 months, the benefit of TAU could no longer be confirmed. The study was registered on 16/01/2017 (ClinicalTrials.gov, NCT03022760).
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Affiliation(s)
- Anja Beno
- Institute of Stress Medicine, Region Västra Götaland, Carl Skottsbergs Gata 22B, SE-413 19, Gothenburg, Sweden.
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Monica Bertilsson
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Kristina Holmgren
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Kristina Glise
- Institute of Stress Medicine, Region Västra Götaland, Carl Skottsbergs Gata 22B, SE-413 19, Gothenburg, Sweden
| | - Anders Pousette
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- The Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Karin Segerfelt
- Institute of Stress Medicine, Region Västra Götaland, Carl Skottsbergs Gata 22B, SE-413 19, Gothenburg, Sweden
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Lisa Björk
- Institute of Stress Medicine, Region Västra Götaland, Carl Skottsbergs Gata 22B, SE-413 19, Gothenburg, Sweden
- The Department of Work Science and Sociology, University of Gothenburg, Gothenburg, Sweden
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Forbes A, Keleher MR, Venditto M, DiBiasi F. Assessing Patient Adherence to and Engagement With Digital Interventions for Depression in Clinical Trials: Systematic Literature Review. J Med Internet Res 2023; 25:e43727. [PMID: 37566447 PMCID: PMC10457707 DOI: 10.2196/43727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 04/24/2023] [Accepted: 06/28/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND New approaches to the treatment of depression are necessary for patients who do not respond to current treatments or lack access to them because of barriers such as cost, stigma, and provider shortage. Digital interventions for depression are promising; however, low patient engagement could limit their effectiveness. OBJECTIVE This systematic literature review (SLR) assessed how participant adherence to and engagement with digital interventions for depression have been measured in the published literature, what levels of adherence and engagement have been reported, and whether higher adherence and increased engagement are linked to increased efficacy. METHODS We focused on a participant population of adults (aged ≥18 years) with depression or major depressive disorder as the primary diagnosis and included clinical trials, feasibility studies, and pilot studies of digital interventions for treating depression, such as digital therapeutics. We screened 756 unique records from Ovid MEDLINE, Embase, and Cochrane published between January 1, 2000, and April 15, 2022; extracted data from and appraised the 94 studies meeting the inclusion criteria; and performed a primarily descriptive analysis. Otsuka Pharmaceutical Development & Commercialization, Inc (Princeton, New Jersey, United States) funded this study. RESULTS This SLR encompassed results from 20,111 participants in studies using 47 unique web-based interventions (an additional 10 web-based interventions were not described by name), 15 mobile app interventions, 5 app-based interventions that are also accessible via the web, and 1 CD-ROM. Adherence was most often measured as the percentage of participants who completed all available modules. Less than half (44.2%) of the participants completed all the modules; however, the average dose received was 60.7% of the available modules. Although engagement with digital interventions was measured differently in different studies, it was most commonly measured as the number of modules completed, the mean of which was 6.4 (means ranged from 1.0 to 19.7) modules. The mean amount of time participants engaged with the interventions was 3.9 (means ranged from 0.7 to 8.4) hours. Most studies of web-based (34/45, 76%) and app-based (8/9, 89%) interventions found that the intervention group had substantially greater improvement for at least 1 outcome than the control group (eg, care as usual, waitlist, or active control). Of the 14 studies that investigated the relationship between engagement and efficacy, 9 (64%) found that increased engagement with digital interventions was significantly associated with improved participant outcomes. The limitations of this SLR include publication bias, which may overstate engagement and efficacy, and low participant diversity, which reduces the generalizability. CONCLUSIONS Patient adherence to and engagement with digital interventions for depression have been reported in the literature using various metrics. Arriving at more standardized ways of reporting adherence and engagement would enable more effective comparisons across different digital interventions, studies, and populations.
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Affiliation(s)
- Ainslie Forbes
- Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, United States
| | | | | | - Faith DiBiasi
- Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, United States
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Petersson EL, Forsén E, Björkelund C, Hammarbäck L, Hessman E, Weineland S, Svenningsson I. Examining the description of the concept "treatment as usual" for patients with depression, anxiety and stress-related mental disorders in primary health care research - A systematic review. J Affect Disord 2023; 326:1-10. [PMID: 36708952 DOI: 10.1016/j.jad.2023.01.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND In randomized controlled trials (RCTs) within medical research, applied interventions are compared to treatment-as-usual (TAU) as the control condition. The aim of the current study was to examine how the concept of TAU is described when used as control condition in RCTs evaluating treatments for depression, anxiety syndromes, and stress-related mental disorders in primary care. METHOD A systematic review of RCTs utilizing TAU as control group in the RCT in accordance with PRISMA standards was conducted. We used one multidisciplinary database (Scopus), one database focused on nursing (Cinahl), and one medical database (PubMed). The searches were conducted in November 2021 and May 2022. RESULTS The included 32 studies comprised of 7803 participants. The content of TAU was classified as follows: 1) Basic descriptions of TAU lacking a detailed account as well as reference to local or national guidelines, 2) Moderate description of TAU including reference to national or local guidelines or a detailed description 3) Advanced description of TAU including references to national guidelines and a detailed description containing five key concepts: early assessment, accessibility, psychological treatment, medication, somatic examination. 18 studies had basic, 11 moderate, and 3 advanced descriptions of TAU. LIMITATIONS The limitations were that only studies published in English were included. CONCLUSIONS The current study provides an assessment tool with three classification levels for TAU. The description of TAU is still insufficient in RCT studies conducted in primary care, which may affect the interpretation of results. In future research a detailed description of TAU is recommended.
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Affiliation(s)
- E-L Petersson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - E Forsén
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - C Björkelund
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - L Hammarbäck
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - E Hessman
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - S Weineland
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden; Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - I Svenningsson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden.
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10
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Rozental A, Powers M. Cognitive Behaviour Therapy: 50 th anniversary. Cogn Behav Ther 2023; 52:163-175. [PMID: 36924452 DOI: 10.1080/16506073.2023.2189794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- A Rozental
- Department of Psychology, Uppsala University, Uppsal, Sweden.,Department of Clinical Neuroscience, Karolinska Institute, Solna, Sweden
| | - M Powers
- Baylor University Medical Center, Dallas, TX, USA
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11
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Jonsson U, Linton SJ, Ybrandt H, Ringborg A, Leander L, Moberg K, Hultcrantz M, Arnberg FK. 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. J Affect Disord 2023; 322:221-234. [PMID: 36400149 DOI: 10.1016/j.jad.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ulf Jonsson
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Department of Medical Sciences, Child and Adolescent Psychiatry, Uppsala University, Uppsala, Sweden.
| | - Steven J Linton
- Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | | | - Anna Ringborg
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Lina Leander
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Klas Moberg
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Monica Hultcrantz
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Filip K Arnberg
- National Centre for Disaster Psychiatry, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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12
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Berg I, Hovne V, Carlbring P, Bernhard-Oettel C, Oscarsson M, Mechler J, Lindqvist K, Topooco N, Andersson G, Philips B. "Good job!": Therapists' encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression. Internet Interv 2022; 30:100592. [PMID: 36439193 PMCID: PMC9682339 DOI: 10.1016/j.invent.2022.100592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/16/2022] Open
Abstract
Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.
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Affiliation(s)
- Ida Berg
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Vera Hovne
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden,Corresponding author at: Department of Psychology, Stockholm University, SE-106 91 Stockholm, Sweden.
| | | | - Martin Oscarsson
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Jakob Mechler
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Karin Lindqvist
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Naira Topooco
- Department of Psychology, Uppsala University, Uppsala, Sweden,Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Björn Philips
- Department of Psychology, Stockholm University, Stockholm, Sweden
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13
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Børtveit L, Dechsling A, Sütterlin S, Nordgreen T, Nordahl-Hansen A. Guided Internet-Delivered Treatment for Depression: Scoping Review. JMIR Ment Health 2022; 9:e37342. [PMID: 36194467 PMCID: PMC9579933 DOI: 10.2196/37342] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/01/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder. OBJECTIVE The aim of this study was to provide an overview of this research area and identify potential gaps in the research. METHODS In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition. RESULTS A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion. CONCLUSIONS This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.
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Affiliation(s)
- Line Børtveit
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway.,Faculty of Health Sciences, Department of Behavioral Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Anders Dechsling
- Department of Education, ICT, and Learning, Østfold University College, Halden, Norway
| | - Stefan Sütterlin
- Faculty of Health, Welfare and Organisation, Østfold University College, Halden, Norway.,Faculty of Computer Science, Albstadt-Sigmaringen University, Sigmaringen, Germany
| | - Tine Nordgreen
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Departement of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Anders Nordahl-Hansen
- Department of Education, ICT, and Learning, Østfold University College, Halden, Norway
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14
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Wright JH, Owen J, Eells TD, Antle B, Bishop LB, Girdler R, Harris LM, Wright RB, Wells MJ, Gopalraj R, Pendleton ME, Ali S. Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2146716. [PMID: 35142833 PMCID: PMC8832170 DOI: 10.1001/jamanetworkopen.2021.46716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. OBJECTIVES To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. INTERVENTIONS CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. MAIN OUTCOMES AND MEASURES The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8. RESULTS The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02700009.
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Affiliation(s)
- Jesse H. Wright
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jesse Owen
- Department of Counseling Psychology, University of Denver, Denver, Colorado
| | - Tracy D. Eells
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, Kentucky
| | - Becky Antle
- Kent School of Social Work, University of Louisville, Louisville, Kentucky
| | - Laura B. Bishop
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Renee Girdler
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Norton Healthcare, Norton Community Medical Associates, Louisville, Kentucky
| | - Lesley M. Harris
- Kent School of Social Work, University of Louisville, Louisville, Kentucky
| | - R. Brent Wright
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michael J. Wells
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Baptist Health, Baptist Health Medical Group Primary Care, Louisville, Kentucky
| | - Rangaraj Gopalraj
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Norton Healthcare, Norton Community Medical Associates, Louisville, Kentucky
| | - Michael E. Pendleton
- Department of Family and Geriatric Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- now with Baptist Health, Baptist Health Medical Group Primary Care, Louisville, Kentucky
| | - Shehzad Ali
- Mental Health and Addictions Research Group, Department of Health Sciences, University of York, Heslington, United Kingdom
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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15
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Kirk MA, Pirbaglou M, Weerasekera R, Ritvo P. Effectiveness of online cognitive behavioral interventions that include mindfulness for clinically-diagnosed anxiety and depressive disorders: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2021. [DOI: 10.1080/00207411.2021.1959807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Megan A. Kirk
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Meysam Pirbaglou
- School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Rasanjala Weerasekera
- Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Canada
| | - Paul Ritvo
- School of Kinesiology and Health Science, York University, Toronto, Canada
- Department of Psychology, York University, Toronto, Canada
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
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16
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How are guide profession and routine care setting related to adherence and symptom change in iCBT for depression? - an explorative log-data analysis. Internet Interv 2021; 26:100476. [PMID: 34804811 PMCID: PMC8590032 DOI: 10.1016/j.invent.2021.100476] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND While the antidepressant efficacy of guided digital interventions has been proven in randomized controlled trials, findings from routine care are less clear. Low adherence rates are common and limit the potential effectiveness. Adherence has been linked to sociodemographic variables and the amount of guidance, but the role of the guide's profession and their work setting has not yet been studied for routine care. METHODS Routinely collected log data from a digital intervention for depressed patients (iFightDepression tool) were analyzed in an exploratory manner. The sample is a convenience sample from routine care, where guidance is provided by general practitioners (GP), certified psychotherapists (PT) or medical doctors specialized in mental health. Log data from 2184 patients were analyzed and five usage parameters were extracted to measure adherence (first-to-last login, time on tool, number of sessions, workshops completed and minimal dose). Multiple logistic regression was used to analyze relations between the guide's profession and clinical context as well as other covariates and adherence and symptom change on a brief depression questionnaire (PHQ-9). RESULTS The analyses showed a significant relation of guide profession and adherence. Guidance by PT was associated to the highest adherence scores (reference category). The odds ratios (ORs) of scoring above the median in each usage parameter for patients guided by GPs were 0.50-0.63 (all ps < 0.002) and 0.61-0.80 (p = .002-0.197) for MH. Higher age, initial PHQ-9 score and self-reported diagnosis of depression were also significantly associated with higher adherence scores. In a subsample providing enough data on the PHQ-9 (n = 347), no association of guide profession with symptom reduction was found. Instead, a greater reduction was observed for patients with a higher baseline PHQ-9 (β = -0. 39, t(341.75) = -8.814, p < .001) and for those who had achieved minimal dose (β = -2.42, t(340.34) = -4.174, P < .001) and those who had achieved minimal dose and scored high on time on tool (β = 0.22, t(341.75) = 1.965, P = .050). CONCLUSION Being guided by PT was associated with the highest adherence. The lowest adherence was observed in patients who were guided by GP. While no association of guide profession and symptom reduction was found in a subsample, greater adherence was associated with symptom reduction.
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Tokgöz P, Hrynyschyn R, Hafner J, Schönfeld S, Dockweiler C. Digital Health Interventions in Prevention, Relapse, and Therapy of Mild and Moderate Depression: Scoping Review. JMIR Ment Health 2021; 8:e26268. [PMID: 33861201 PMCID: PMC8087966 DOI: 10.2196/26268] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/15/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Depression is a major cause for disability worldwide, and digital health interventions are expected to be an augmentative and effective treatment. According to the fast-growing field of information and communication technologies and its dissemination, there is a need for mapping the technological landscape and its benefits for users. OBJECTIVE The purpose of this scoping review was to give an overview of the digital health interventions used for depression. The main goal of this review was to provide a comprehensive review of the system landscape and its technological state and functions, as well as its evidence and benefits for users. METHODS A scoping review was conducted to provide a comprehensive overview of the field of digital health interventions for the treatment of depression. PubMed, PSYNDEX, and the Cochrane Library were searched by two independent researchers in October 2020 to identify relevant publications of the last 10 years, which were examined using the inclusion and exclusion criteria. To conduct the review, we used Rayyan, a freely available web tool. RESULTS In total, 65 studies were included in the qualitative synthesis. After categorizing the studies into the areas of prevention, early detection, therapy, and relapse prevention, we found dominant numbers of studies in the area of therapy (n=52). There was only one study for prevention, 5 studies for early detection, and 7 studies for relapse prevention. The most dominant therapy approaches were cognitive behavioral therapy, acceptance and commitment therapy, and problem-solving therapy. Most of the studies revealed significant effects of digital health interventions when cognitive behavioral therapy was applied. Cognitive behavioral therapy as the most dominant form was often provided through web-based systems. Combined interventions consisting of web-based and smartphone-based approaches are increasingly found. CONCLUSIONS Digital health interventions for treating depression are quite comprehensive. There are different interventions focusing on different fields of care. While most interventions can be beneficial to achieve a better depression treatment, it can be difficult to determine which approaches are suitable. Cognitive behavioral therapy through digital health interventions has shown good effects in the treatment of depression, but treatment for depression still stays very individualistic.
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Affiliation(s)
- Pinar Tokgöz
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Robert Hrynyschyn
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Health and Nursing Science, Berlin, Germany
| | - Jessica Hafner
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Simone Schönfeld
- School of Public Health, Bielefeld University, Bielefeld, Germany.,LWL-Klinik Lippstadt und Warstein, Lippstadt, Germany.,Universität Witten/Herdecke, Institut für Integrative Gesundheitsversorgung und Gesundheitsförderung, Witten, Germany
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18
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Karyotaki E, Efthimiou O, Miguel C, Bermpohl FMG, Furukawa TA, Cuijpers P. Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry 2021; 78:361-371. [PMID: 33471111 PMCID: PMC8027916 DOI: 10.1001/jamapsychiatry.2020.4364] [Citation(s) in RCA: 321] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/23/2020] [Indexed: 12/11/2022]
Abstract
Importance Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. Objective To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. Data Sources We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. Study Selection Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. Data Extraction and Synthesis We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. Main Outcomes and Measures Patient Health Questionnaire-9 (PHQ-9) scores. Results Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9. Conclusions and Relevance In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
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Affiliation(s)
- Eirini Karyotaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Psychiatry, University of Oxford, Oxford, England
| | - Clara Miguel
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Toshi A. Furukawa
- Department of Clinical Psychology and Psychotherapy, University of Wuppertal, Wuppertal, Germany
- Department of Health Promotion and Human Behavior, Department of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Pim Cuijpers
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Ritvo P, Knyahnytska Y, Pirbaglou M, Wang W, Tomlinson G, Zhao H, Linklater R, Bai S, Kirk M, Katz J, Harber L, Daskalakis Z. Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth With Major Depressive Disorders: Randomized Controlled Trial. J Med Internet Res 2021; 23:e24380. [PMID: 33688840 PMCID: PMC7991990 DOI: 10.2196/24380] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/30/2020] [Accepted: 01/10/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Approximately 70% of mental health disorders appear prior to 25 years of age and can become chronic when ineffectively treated. Individuals between 18 and 25 years old are significantly more likely to experience mental health disorders, substance dependencies, and suicidality. Treatment progress, capitalizing on the tendencies of youth to communicate online, can strategically address depressive disorders. OBJECTIVE We performed a randomized controlled trial (RCT) that compared online mindfulness-based cognitive behavioral therapy (CBT-M) combined with standard psychiatric care to standard psychiatric care alone in youth (18-30 years old) diagnosed with major depressive disorder. METHODS Forty-five participants were randomly assigned to CBT-M and standard care (n=22) or to standard psychiatric care alone (n=23). All participants were provided standard psychiatric care (ie, 1 session per month), while participants in the experimental group received an additional intervention consisting of the CBT-M online software program. Interaction with online workbooks was combined with navigation coaching delivered by phone and secure text messaging. RESULTS In a two-level linear mixed-effects model intention-to-treat analysis, significant between-group differences were found for the Beck Depression Inventory-II score (difference -8.54, P=.01), Quick Inventory of Depressive Symptoms score (difference -4.94, P=.001), Beck Anxiety Inventory score (difference -11.29, P<.001), and Brief Pain Inventory score (difference -1.99, P=.03), while marginal differences were found for the Five Facet Mindfulness Questionnaire-Nonjudging subscale (difference -2.68, P=.05). CONCLUSIONS These results confirm that youth depression can be effectively treated with online CBT-M that can be delivered with less geographic restriction. TRIAL REGISTRATION Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052.
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Affiliation(s)
- Paul Ritvo
- School of Kinesiology and Health Sciences, York University, Toronto, ON, Canada.,Department of Psychology, York University, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Yuliya Knyahnytska
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Meysam Pirbaglou
- School of Kinesiology and Health Sciences, York University, Toronto, ON, Canada
| | - Wei Wang
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - George Tomlinson
- THETA Collaborative, University Health Network, University of Toronto, Toronto, ON, Canada.,Biostatistics Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Haoyu Zhao
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Renee Linklater
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Aboriginal Engagement and Outreach, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Shari Bai
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Megan Kirk
- School of Kinesiology and Health Sciences, York University, Toronto, ON, Canada
| | - Joel Katz
- School of Kinesiology and Health Sciences, York University, Toronto, ON, Canada.,Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Lillian Harber
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Zafiris Daskalakis
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of California San Diego, La Jolla, CA, United States.,Mood and Anxiety Ambulatory Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
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20
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Furukawa TA, Levine SZ, Buntrock C, Ebert DD, Gilbody S, Brabyn S, Kessler D, Björkelund C, Eriksson M, Kleiboer A, van Straten A, Riper H, Montero-Marin J, Garcia-Campayo J, Phillips R, Schneider J, Cuijpers P, Karyotaki E. How can we estimate QALYs based on PHQ-9 scores? Equipercentile linking analysis of PHQ-9 and EQ-5D. EVIDENCE-BASED MENTAL HEALTH 2021; 24:ebmental-2020-300240. [PMID: 33653738 PMCID: PMC8311092 DOI: 10.1136/ebmental-2020-300240] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Quality-adjusted life years (QALYs) are widely used to measure the impact of various diseases on both the quality and quantity of life and in their economic valuations. It will be clinically important and informative if we can estimate QALYs based on measurements of depression severity. OBJECTIVE To construct a conversion table from the Patient Health Questionnaire-9 (PHQ-9), the most frequently used depression scale in recent years, to the Euro-Qol Five Dimensions Three Levels (EQ-5D-3L), one of the most commonly used instruments to assess QALYs. METHODS We obtained individual participant data of randomised controlled trials of internet cognitive-behavioural therapy which had administered depression severity scales and the EQ-5D-3L at baseline and at end of treatment. Scores from depression scales were all converted into the PHQ-9 according to the validated algorithms. We used equipercentile linking to establish correspondences between the PHQ-9 and the EQ-5D-3L. FINDINGS Individual-level data from five trials (total N=2457) were available. Subthreshold depression (PHQ-9 scores between 5 and 10) corresponded with EQ-5D-3L index values of 0.9-0.8, mild major depression (10-15) with 0.8-0.7, moderate depression (15-20) with 0.7-0.5 and severe depression (20 or higher) with 0.6-0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L score by 0.03 and a ten-point improvement by approximately 0.25. CONCLUSIONS AND CLINICAL IMPLICATIONS The conversion table between the PHQ-9 and the EQ-5D-3L scores will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments.
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Affiliation(s)
- Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - Stephen Z Levine
- Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Claudia Buntrock
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - David D Ebert
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | - David Kessler
- Population Health Sciences & National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Cecilia Björkelund
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Maria Eriksson
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Annet Kleiboer
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jesus Montero-Marin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Javier Garcia-Campayo
- Aragon Institute for Health Research (IIS Aragón), Miguel Servet University Hospital, Zaragoza, Spain
- Primary Care Prevention and Health Promotion Research Network, RedIAPP, Madrid, Spain
| | - Rachel Phillips
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Justine Schneider
- School of Sociology & Social Policy and Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Eirini Karyotaki
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Köhnen M, Dreier M, Seeralan T, Kriston L, Härter M, Baumeister H, Liebherz S. Evidence on Technology-Based Psychological Interventions in Diagnosed Depression: Systematic Review. JMIR Ment Health 2021; 8:e21700. [PMID: 33565981 PMCID: PMC7904404 DOI: 10.2196/21700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/30/2020] [Accepted: 11/18/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Evidence on technology-based psychological interventions (TBIs) for the treatment of depression is rapidly growing and covers a broad scope of research. Despite extensive research in this field, guideline recommendations are still limited to the general effectiveness of TBIs. OBJECTIVE This study aims to structure evidence on TBIs by considering different application areas (eg, TBIs for acute treatment and their implementation in health care, such as stand-alone interventions) and treatment characteristics (eg, therapeutic rationale of TBIs) to provide a comprehensive evidence base and to identify research gaps in TBIs for diagnosed depression. Moreover, the reporting of negative events in the included studies is investigated in this review to enable subsequent safety assessment of the TBIs. METHODS Randomized controlled trials on adults diagnosed with unipolar depression receiving any kind of psychotherapeutic treatment, which was at least partly delivered by a technical medium, were eligible for inclusion in our preregistered systematic review. We searched for trials in CENTRAL (Cochrane Central Register of Controlled Trials; until August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL; until the end of January 2018), clinical trial registers, and sources of gray literature (until the end of January 2019). Study selection and data extraction were conducted by 2 review authors independently. RESULTS Database searches resulted in 15,546 records, of which 241 publications were included, representing 83 completed studies and 60 studies awaiting classification (ie, preregistered studies, study protocols). Almost all completed studies (78/83, 94%) addressed the acute treatment phase, being largely either implemented as stand-alone interventions (66/83, 80%) or blended treatment approaches (12/83, 14%). Studies on TBIs for aftercare (4/83, 5%) and for bridging waiting periods (1/83, 1%) were scarce. Most TBI study arms (n=107) were guided (59/107, 55.1%), delivered via the internet (80/107, 74.8%), and based on cognitive behavioral treatment approaches (88/107, 79.4%). Almost all studies (77/83, 93%) reported information on negative events, considering dropouts from treatment as a negative event. However, reports on negative events were heterogeneous and largely unsystematic. CONCLUSIONS Research has given little attention to studies evaluating TBIs for aftercare and for bridging waiting periods in people with depression, even though TBIs are seen as highly promising in these application areas; thus, high quality studies are urgently needed. In addition, the variety of therapeutic rationales on TBIs has barely been represented by identified studies hindering the consideration of patient preferences when planning treatment. Finally, future studies should use specific guidelines to systematically assess and report negative events. TRIAL REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO) CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2018-028042.
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Affiliation(s)
- Moritz Köhnen
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mareike Dreier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tharanya Seeralan
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Levente Kriston
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harald Baumeister
- Department for Clinical Psychology and Psychotherapy, Ulm University, Ulm, Germany
| | - Sarah Liebherz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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22
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Schmaling K, Kaplan RM, Porzsolt F. Efficacy and effectiveness studies of depression are not well-differentiated in the literature: a systematic review. BMJ Evid Based Med 2021; 26:28-30. [PMID: 32188642 DOI: 10.1136/bmjebm-2020-111337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND In the literature on the treatment of depression, efficacy and effectiveness research have different purposes and should apply different research methodologies. OBJECTIVE The purpose of the study was to review characteristics of depression treatment studies identified using efficacy or effectiveness search terms. We considered subject inclusion and exclusion criteria; numbers of subjects enrolled and the proportion in the primary analyses; inclusion of a Consolidated Standards of Reporting Trials (CONSORT) flow diagram; use of random assignment; use of placebo control conditions; lengths of treatment and follow-up; primary outcome variable; trial registration; journal impact factor. STUDY SELECTION Studies indexed as efficacy AND 'real-world' AND depression or effectiveness AND 'real-world' AND depression in PubMed up to 18 May 2019. FINDINGS 27 studies met the inclusion criteria: 13 effectiveness studies, 6 efficacy studies and 8 studies indexed as both effectiveness and efficacy. Studies identified as effectiveness, efficacy, or both differed on three outcome measures: the inclusion criteria were lengthier for efficacy than for effectiveness studies; efficacy studies were more likely to have a placebo control condition than effectiveness studies; and the journal impact factor was lower for effectiveness studies than for studies from the efficacy search or studies identified by both searches. CONCLUSIONS Efficacy and effectiveness research hypothetically use different methodologies, but the efficacy and effectiveness literatures in the treatment of depression were comparable for most of the coded characteristics. The lack of distinguishable characteristics suggests that variably applied terminology may hinder efforts to narrow the gap between research and practice. PROSPERO REGISTRATION NUMBER: #CRD42019136840.
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Affiliation(s)
- Karen Schmaling
- Psychology, Washington State University, Vancouver, Washington, USA
| | - Robert M Kaplan
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California, USA
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23
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Niles AN, Axelsson E, Andersson E, Hedman-Lagerlöf E, Carlbring P, Andersson G, Johansson R, Widén S, Driessen J, Santoft F, Ljótsson B. Internet-based cognitive behavior therapy for depression, social anxiety disorder, and panic disorder: Effectiveness and predictors of response in a teaching clinic. Behav Res Ther 2021; 136:103767. [DOI: 10.1016/j.brat.2020.103767] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022]
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Köhnen M, Kriston L, Härter M, Baumeister H, Liebherz S. Effectiveness and acceptance of technology-based psychological interventions for the acute treatment of unipolar depression: a systematic review and meta-analysis (Preprint). J Med Internet Res 2020; 23:e24584. [PMID: 36260395 PMCID: PMC8386371 DOI: 10.2196/24584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/08/2021] [Accepted: 04/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background Evidence on technology-based psychological interventions (TBIs) for the acute treatment of depression is rapidly growing. Despite extensive research in this field, there is a lack of research determining effectiveness and acceptance of TBIs considering different application formats in people with a formally diagnosed depressive disorder. Objective The goal of the review was to investigate the effectiveness and acceptance of TBIs in people with diagnosed depression with particular focus on application formats (stand-alone interventions, blended treatments, collaborative and/or stepped care interventions). Methods Studies investigating adults with diagnosed unipolar depressive disorders receiving any kind of psychotherapeutic treatment delivered (at least partly) by a technical medium and conducted as randomized controlled trials (RCTs) were eligible for inclusion. We searched CENTRAL (Cochrane Central Register of Controlled Trials; August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL (January 2018), clinical trial registers, and sources of grey literature (January 2019). Two independent authors decided about study inclusion and extracted data. We performed random effects meta-analyses to synthesize the data. Results Database searches resulted in 15,546 records of which 78 completed studies were included. TBIs delivered as stand-alone interventions showed positive effects on posttreatment depression severity when compared to treatment as usual (SMD –0.44, 95% CI –0.73 to –0.15, k=10; I²=86%), attention placebo (SMD –0.51, 95% CI –0.73 to –0.30; k=12; I²=66%), and waitlist controls (SMD –1.01, 95% CI –1.23 to –0.79; k=19; I²=73%). Superior long-term effects on depression severity were shown when TBIs were compared to treatment as usual (SMD –0.24, 95% CI –0.41 to –0.07; k=6; I²=48%) attention placebo (SMD –0.23, 95% CI –0.40 to –0.07; k=7; I²=21%) and waitlist controls (SMD –0.74, 95% CI –1.31 to –0.18; k=3; I²=79%). TBIs delivered as blended treatments (providing a TBI as an add-on to face-to-face treatment) yielded beneficial effects on posttreatment depression severity (SMD –0.27, 95% CI –0.48 to –0.05; k=8; I²=53%) compared to face-to-face treatments only. Additionally, TBIs delivered within collaborative care trials were more effective in reducing posttreatment (SMD –0.20, 95% CI –0.36 to –0.04; k=2; I²=0%) and long-term (SMD –0.23, 95% CI –0.39 to –0.07; k=2; I²=0%) depression severity than usual care. Dropout rates did not differ between the intervention and control groups in any comparison (all P≥.09). Conclusions We found that TBIs are effective not only when delivered as stand-alone interventions but also when they are delivered as blended treatments or in collaborative care trials for people with diagnosed depression. Our results may be useful to inform routine care, since we focused specifically on different application formats, formally diagnosed patients, and the long-term effectiveness of TBIs. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2018-028042
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Affiliation(s)
- Moritz Köhnen
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Levente Kriston
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harald Baumeister
- Department for Clinical Psychology and Psychotherapy, University of Ulm, Ulm, Germany
| | - Sarah Liebherz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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25
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Sander L, Gerhardinger K, Bailey E, Robinson J, Lin J, Cuijpers P, Mühlmann C. Suicide risk management in research on internet-based interventions for depression: A synthesis of the current state and recommendations for future research. J Affect Disord 2020; 263:676-683. [PMID: 31757622 DOI: 10.1016/j.jad.2019.11.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/05/2019] [Accepted: 11/09/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The number of studies examining internet-based interventions (IBIs) for depression is increasing. Although many individuals with depression experience suicidal ideation, there is only insufficient information available on how to manage and support individuals at risk of suicide in IBI trials. Here, we examined the current practice regarding the management of individuals experiencing suicidal thoughts or behaviors in studies of IBIs for depression. METHODS Information pertaining to the management of suicidality was extracted from 24 studies. Additionally, researchers in the field completed a questionnaire (n = 13) before being interviewed (n = 11) about their procedures and considerations regarding the management of suicidality. RESULTS In most trials (N = 17; 71%), individuals at risk of suicide were excluded based on varying criteria. N = 7 studies used structured interviews and N = 5 studies used single items of self-report questionnaires for assessing suicidality. The nature and degree of support provided to individuals at risk of suicide varied and only one intervention comprised suicide-specific content. LIMITATIONS Most experts referred to research on interventions with some level of human support (e.g. written feedback) which might limit the representativeness of the results of the interviews for unguided interventions. CONCLUSIONS Suicidality is often treated more as an exclusion criterion rather than a treatable condition in research on IBIs for depression. This paper provides an overview of the current practice and gives recommendations for the design of future trials.
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Affiliation(s)
- Lasse Sander
- Department of Rehabilitation Psychology and Psychotherapy, Albert-Ludwigs-University Freiburg, Institute of Psychology, Engelbergerstr. 41, D-79085 Freiburg, Germany.
| | - Katharina Gerhardinger
- Department of Rehabilitation Psychology and Psychotherapy, Albert-Ludwigs-University Freiburg, Institute of Psychology, Engelbergerstr. 41, D-79085 Freiburg, Germany
| | - Eleanor Bailey
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Australia; Swinburne University of Technology, Melbourne, Australia
| | - Jo Robinson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia; Centre for Youth Mental Health, University of Melbourne, Australia
| | - Jiaxi Lin
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hauptstrasse 5, D-79104 Freiburg, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro-, and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, BT 1081, Amsterdam, the Netherlands
| | - Charlotte Mühlmann
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Hellerup, Denmark; The University of Copenhagen, Denmark
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Internet-based CBT for patients with depressive disorders in primary and psychiatric care: Is it effective and does comorbidity affect outcome? Internet Interv 2019; 19:100303. [PMID: 32055451 PMCID: PMC7005448 DOI: 10.1016/j.invent.2019.100303] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 02/05/2023] Open
Abstract
Internet-based cognitive behavior therapy (ICBT) has proved effective in reducing mild to moderate depressive symptoms. However, only a few studies have been conducted in a regular healthcare setting which limits the generalizability of the results. The influence of psychiatric comorbidity on outcome is not well understood. In the current study, patients with mild to moderate depressive symptoms in primary and psychiatric care were interviewed using the SCID-I and SCID-II to assess psychiatric diagnoses. Those included were randomly allocated to ICBT (n = 48) or to an active control condition (n = 47). Both groups received therapist support. At post-treatment, ICBT had reduced depressive symptoms on the BDI-II more than the active control intervention (p = .021). However, the difference between groups was no longer significant at the 6-, 12- or 24-month follow-ups. The within-group effect size after ICBT (BDI-II) was large (d = 1.4). A comorbid anxiety disorder didn't moderate the outcome, while the presence of a personality disorder predicted significantly less improvement in depressive symptoms. ICBT had a large effect on depressive symptoms in a sample from regular healthcare. It is possible to obtain a large effect from ICBT despite comorbid anxiety, however, including patients with a comorbid personality disorder in the current form of ICBT seems questionable.
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27
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Zagorscak P, Bohn J, Heinrich M, Kampisiou C, Knaevelsrud C. Only on Invitation? How the Recruitment Strategy Determines Who Is Treated Online. VERHALTENSTHERAPIE 2019. [DOI: 10.1159/000503407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Zagorscak P, Bohn J, Heinrich M, Kampisiou C, Knaevelsrud C. Nur auf Einladung? Wie die Rekrutierungsstrategie beeinflusst, wer online behandelt wird. VERHALTENSTHERAPIE 2019. [DOI: 10.1159/000502018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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29
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Ritvo P, Daskalakis ZJ, Tomlinson G, Ravindran A, Linklater R, Kirk Chang M, Knyahnytska Y, Lee J, Alavi N, Bai S, Harber L, Jain T, Katz J. An Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth Diagnosed With Major Depressive Disorders: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e11591. [PMID: 31359869 PMCID: PMC6690226 DOI: 10.2196/11591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 12/30/2022] Open
Abstract
Background About 70% of all mental health disorders appear before the age of 25 years. When untreated, these disorders can become long-standing and impair multiple life domains. When compared with all Canadian youth (of different ages), individuals aged between 15 and 25 years are significantly more likely to experience mental health disorders, substance dependencies, and risks for suicidal ideation and death by suicide. Progress in the treatment of youth, capitalizing on their online responsivity, can strategically address depressive disorders. Objective We will conduct a randomized controlled trial to compare online mindfulness-oriented cognitive behavioral therapy (CBT-M) combined with standard psychiatric care versus psychiatric care alone in youth diagnosed with major depressive disorder. We will enroll 168 subjects in the age range of 18 to 30 years; 50% of subjects will be from First Nations (FN) backgrounds, whereas the other 50% will be from all other ethnic backgrounds. There will be equal stratification into 2 intervention groups (INT1 and INT2) and 2 wait-list control groups (CTL1 and CTL2) with 42 subjects per group, resulting in an equal number of INT1 and CTL1 of FN background and INT2 and CTL2 of non-FN background. Methods The inclusion criteria are: (1) age 18 to 30 years, FN background or other ethnicity; (2) Beck Depression Inventory (BDI)-II of at least mild severity (BDI-II score ≥14) and no upper limit; (3) Mini-International Neuropsychiatric Interview (MINI)–confirmed psychiatric diagnosis of major depressive disorder; and (4) fluent in English. All patients are diagnosed by a Centre for Addiction and Mental Health psychiatrist, with diagnoses confirmed using the MINI interview. The exclusion criteria are: (1) individuals receiving weekly structured psychotherapy; (2) individuals who meet the Diagnostic and Statistical Manual of Mental Disorders criteria for severe alcohol/substance use disorder in the past 3 months, or who demonstrate clinically significant suicidal ideation defined as imminent intent, or who have attempted suicide in the past 6 months; and (3) individuals with comorbid diagnoses of borderline personality, schizophrenia, bipolar disorder, and/or obsessive compulsive disorder. All subjects are provided standard psychiatric care defined as 1 monthly session that focuses on appropriate medication, with session durations of 15 to 30 min. Experimental subjects receive an additional intervention consisting of the CBT-M online software program (in collaboration with Nex J Health, Inc). Exposure to and interaction with the online workbooks are combined with navigation-coaching delivered by phone and secure text message interactions. Results The outcomes selected, combined with measurement blinding, are key features in assessing whether significant benefits regarding depression and anxiety symptoms occur. Conclusions If results confirm the hypothesis that youth can be effectively treated with online CBT-M, effective services may be widely delivered with less geographic restriction. International Registered Report Identifier (IRRID) PRR1-10.2196/11591
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Affiliation(s)
- Paul Ritvo
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Zafiris J Daskalakis
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - George Tomlinson
- THETA and Biostatistics Unit, University Health Network, Toronto, ON, Canada
| | - Arun Ravindran
- Campbell Family Mental Health Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Renee Linklater
- Aboriginal Engagement and Outreach, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Megan Kirk Chang
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Yuliya Knyahnytska
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Jonathan Lee
- Child and Youth Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Nazanin Alavi
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Shari Bai
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Lillian Harber
- Mood and Anxiety Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tania Jain
- Mood and Anxiety Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON, Canada
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Santoft F, Axelsson E, Öst LG, Hedman-Lagerlöf M, Fust J, Hedman-Lagerlöf E. Cognitive behaviour therapy for depression in primary care: systematic review and meta-analysis. Psychol Med 2019; 49:1266-1274. [PMID: 30688184 DOI: 10.1017/s0033291718004208] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Depression is common in primary care, and most patients prefer psychological treatment over pharmacotherapy. Cognitive behaviour therapy (CBT) is an effective treatment, but there are gaps in current knowledge about CBT in the primary care context, especially with regard to long-term effects and the efficacy of specific delivery formats. This is an obstacle to the integration of primary care and specialist psychiatry. We conducted a systematic review and meta-analysis of randomised controlled trials of CBT for primary care patients with depression to investigate the effect of CBT for patients with depression in primary care. A total of 34 studies, with 2543 patients in CBT and 2815 patients in control conditions, were included. CBT was more effective than the control conditions [g = 0.22 (95% confidence interval (CI) 0.15-0.30)], and the effect was sustained at follow-up [g = 0.17 (95% CI 0.10-0.24)]. CBT also led to a higher response rate [odds ratio (OR) = 2.47 (95% CI 1.60-3.80)] and remission rate [OR = 1.56 (95% CI 1.15-2.14)] than the control conditions. Heterogeneity was moderate. The controlled effect of CBT was significant regardless of whether patients met diagnostic criteria for depression, scored above a validated cut-off for depression, or merely had depressive symptoms. CBT also had a controlled effect regardless of whether the treatment was delivered as individual therapy, group therapy or therapist-guided self-help. We conclude that CBT appears to be effective for patients with depression in primary care, and recommend that patients with mild to moderate depression be offered CBT in primary care.
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Affiliation(s)
- Fredrik Santoft
- Division of Psychology, Department of Clinical Neuroscience,Karolinska Institutet,Stockholm,Sweden
| | - Erland Axelsson
- Division of Psychology, Department of Clinical Neuroscience,Karolinska Institutet,Stockholm,Sweden
| | - Lars-Göran Öst
- Division of Psychology, Department of Clinical Neuroscience,Karolinska Institutet,Stockholm,Sweden
| | - Maria Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience,Karolinska Institutet,Stockholm,Sweden
| | - Jens Fust
- Neuro, Department of Clinical Neuroscience,Karolinska Institutet,Stockholm,Sweden
| | - Erik Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience,Karolinska Institutet,Stockholm,Sweden
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31
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Zhang A, Borhneimer LA, Weaver A, Franklin C, Hai AH, Guz S, Shen L. Cognitive behavioral therapy for primary care depression and anxiety: a secondary meta-analytic review using robust variance estimation in meta-regression. J Behav Med 2019; 42:1117-1141. [PMID: 31004323 DOI: 10.1007/s10865-019-00046-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/10/2019] [Indexed: 01/02/2023]
Abstract
Cognitive-behavioral therapy (CBT) is well supported for treating depressive and anxiety disorders. Trials of CBT for anxiety and depression in primary care have increased over the past decade, yet only one meta-analysis, published in 2015, examined this topic and the scope of that review is relatively narrow. This study conducted a systematic review and meta-analysis of primary care based CBT for depression and anxiety. A search of seven electronic databases, six professional websites, and reference lists from articles meeting inclusion criteria was conducted for studies published between 1900 and November 2018. Fifty-seven eligible studies (including 10,701 participants; 221 effect sizes) of randomized controlled trials were eligible and included for meta-analysis using robust variance estimation in meta-regression. Outcome indicators were depression and anxiety measures. An overall significant treatment effect, d = 0.400, 95% CI (0.235, 0.566), p < 0.001, of CBT for depression and anxiety disorders in primary care was identified. Subgroup analyses indicated significant treatment effect for: (1) depressive (d = 0.425, p < 0.001) and anxiety (d = 0.393, p < 0.01) outcomes, (2) studies conducted inside primary care (d = 0.412, p < 0.001), (3) studies using individual-based CBT (d = 0.412, p < 0.001), (4) studies without primary care physician involvement (d = 0.395, p < 0.001), and (5) studies using both tele-health (d = 0.563, p < 0.001) and in-person CBT (d = 0.363, p < 0.001). The percentage of White participants, treatment composition (CBT only versus CBT + other approaches), and treatment duration were significant moderators. Implications for clinical practice are discussed based on both moderator and subgroup analysis results.
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Affiliation(s)
- Anao Zhang
- School of Social Work, University of Michigan, 1080 S. University Ave., School of Social Work Building, Ann Arbor, MI, 48109, USA.
| | - Lindsay A Borhneimer
- School of Social Work, University of Michigan, 1080 S. University Ave., School of Social Work Building, Ann Arbor, MI, 48109, USA
| | - Addie Weaver
- School of Social Work, University of Michigan, 1080 S. University Ave., School of Social Work Building, Ann Arbor, MI, 48109, USA
| | - Cynthia Franklin
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Audrey Hang Hai
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Samantha Guz
- School of Social Service Administration, The University of Chicago, Chicago, IL, USA
| | - Li Shen
- Department of Sociology and Social Work, Shanghai Normal University, Shanghai, China
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32
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Antle BF, Owen JJ, Eells TD, Wells MJ, Harris LM, Cappiccie A, Wright B, Williams SM, Wright JH. Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care. Contemp Clin Trials 2019; 78:46-52. [PMID: 30572162 DOI: 10.1016/j.cct.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/30/2018] [Accepted: 11/02/2018] [Indexed: 01/17/2023]
Abstract
Computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care will be evaluated in a trial with 240 patients randomly assigned to CCBT or treatment as usual (TAU). The study will disseminate a therapy method found to be effective in psychiatric settings into primary care - a setting in which there have been significant problems in the delivery of adequate, evidence-based treatment for depression. The study will include a high percentage of disadvantaged (low-income) patients - a population that has been largely ignored in previous research in CCBT. There have been no previous studies of CCBT for depression in primary care that have enrolled large numbers of disadvantaged patients. The form of CCBT used in this study is designed to increase access to effective therapy, provide a cost-effective method, and be a sustainable model for wide-spread use in primary care. In order to deliver therapy in a practical manner that can be replicated in other primary care practices, patients with significant symptoms of depression will receive treatment with an empirically supported computer program that builds cognitive-behavior therapy skills. Support for CCBT will be provided by telephone and/or e-mail contact with a care coordinator (CC) instead of face-to-face treatment with a cognitive-behavior therapist. Outcome will be assessed by measuring CCBT completion rate, comprehension of CBT concepts, and satisfaction with treatment, in addition to ratings of depressive symptoms, negative thoughts, and quality of life. The cost-effectiveness analysis and exploration of possible predictors of outcome should help clinicians, health care organizations, and others plan further dissemination of CCBT in primary care.
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Affiliation(s)
- Becky F Antle
- Kent School of Social Work, University of Louisville, United States.
| | - Jesse J Owen
- Department of Counseling Psychology, Denver University, United States
| | - Tracy D Eells
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, United States
| | - Michael J Wells
- Department of Social Work, Western Kentucky University, United States
| | - Lesley M Harris
- Kent School of Social Work, University of Louisville, United States
| | - Amy Cappiccie
- Department of Social Work, Western Kentucky University, United States
| | - Brent Wright
- Department of Counseling Psychology, Denver University, United States
| | - Sara M Williams
- Kent School of Social Work, University of Louisville, United States
| | - Jesse H Wright
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, United States
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Massoudi B, Holvast F, Bockting CLH, Burger H, Blanker MH. The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis. J Affect Disord 2019; 245:728-743. [PMID: 30447572 DOI: 10.1016/j.jad.2018.11.050] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 09/21/2018] [Accepted: 11/03/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Psychological interventions are labor-intensive and expensive, but e-health interventions may support them in primary care. In this study, we systematically reviewed the effectiveness and cost-effectiveness of e-health interventions for depressive and anxiety symptoms and disorders in primary care. METHODS We searched MEDLINE, Cochrane library, Embase, and PsychINFO until January 2018, for randomized controlled trials of e-health interventions for depression or anxiety in primary care. Two reviewers independently screened the identified publications, extracted data, and assessed risk of bias using the Cochrane Collaboration's tool. RESULTS Out of 3617 publications, we included 14 that compared 33 treatments in 4183 participants. Overall, the methodological quality was poor to fair. The pooled effect size of e-health interventions was small (standardized mean difference = -0.19, 95%CI -0.31 to -0.06) for depression compared to control groups in the short-term, but this was maintained in the long-term (standardized mean difference = -0.22, 95%CI -0.35 to -0.09). Further analysis showed that e-health for depression had a small effect compared to care as usual and a moderate effect compared to waiting lists. One trial on anxiety showed no significant results. Four trials reported on cost-effectiveness. LIMITATIONS The trials studied different types of e-health interventions and had several risks of bias. Moreover, only one study was included for anxiety. CONCLUSIONS E-health interventions for depression have a small effect in primary care, with a moderate effect compared to waiting lists. The approach also appeared to be cost-effective for depression. However, we found no evidence for its effectiveness for anxiety.
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Affiliation(s)
- Btissame Massoudi
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, the Netherlands.
| | - Floor Holvast
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, the Netherlands.
| | - Claudi L H Bockting
- University of Utrecht, Department of Clinical Psychology, Utrecht, the Netherlands; University of Groningen, Department of Clinical Psychology, Groningen, the Netherlands.
| | - Huibert Burger
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, the Netherlands.
| | - Marco H Blanker
- University of Groningen, University Medical Center Groningen, Department of General Practice, Groningen, the Netherlands.
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Zhang A, Franklin C, Jing S, Bornheimer LA, Hai AH, Himle JA, Kong D, Ji Q. The effectiveness of four empirically supported psychotherapies for primary care depression and anxiety: A systematic review and meta-analysis. J Affect Disord 2019; 245:1168-1186. [PMID: 30699860 DOI: 10.1016/j.jad.2018.12.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/14/2018] [Accepted: 12/08/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Depressive and anxiety disorders are highly prevalent and detrimental in primary care settings. However, there are gaps in the literature concerning effectiveness and generalizability of empirically supported interventions and treatment of both depression and anxiety in primary care settings. The aim of this review is to systematically assess and meta-analyze the effectiveness of brief empirically-supported psychotherapies for treating depression and/or anxiety in primary care. METHODS Seven electronic databases, five professional websites and manual search of reference lists were searched through April 2017 for randomized controlled trials (RCTs) of four psychotherapies treating primary care depression and anxiety: cognitive-behavior therapy (CBT), problem-solving therapy (PST), motivational interviewing (MI), and solution-focused brief therapy (SFBT). RESULTS From an initial pool of 1140 articles, 179 articles were eligible for full-text review and 65 articles were included for final analysis. Sixty-five articles containing 198 effect sizes reported an overall treatment effect size of d = 0.462, p < 0.001. Single-predictor meta-regression indicated that marital status, treatment modality (individual versus group), and treatment composition were significant moderators. Multiple-predictor meta-regression discovered treatment setting (inside versus outside primary care) significantly moderated treatment effect, b = -0.863, p = 0.039 after controlling for other intervention characteristics. CONCLUSION Treatment effects were found for CBT and PST, both for depressive and anxiety disorders. Interventions delivered outside primary care settings were more effective than those within, individual treatment had greater treatment effects compared to group treatment, and both technology-assisted and in-person treatments were found to be effective.
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Affiliation(s)
- Anao Zhang
- University of Michigan, School of Social Work, United States; Shanghai Children's Medical Center, China.
| | - Cynthia Franklin
- The University of Texas at Austin, Steve Hicks School of Social Work, United States
| | - Shijie Jing
- East China University of Political Science and Law, School of Social Development, China
| | | | - Audrey Hang Hai
- The University of Texas at Austin, Steve Hicks School of Social Work, United States
| | - Joseph A Himle
- University of Michigan, School of Social Work, United States; University of Michigan, Department of Psychiatry
| | - Dexia Kong
- Rutgers, The State University of New Jersey, Institute for Health, Health Care Policy and Aging Research, United States
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Sogomonjan M, Kerikmäe T, Ööpik P, Ross P. A report on the survey. Attitudes of Estonian healthcare professionals to internet-delivered cognitive behavioural therapy. COGENT PSYCHOLOGY 2019. [DOI: 10.1080/23311908.2019.1637623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Melita Sogomonjan
- Department of Law, Tallinn University of Technology, Tallinn, Estonia
| | - Tanel Kerikmäe
- Department of Law, Tallinn University of Technology, Tallinn, Estonia
| | - Pille Ööpik
- Department of Family Medicine, University of Tartu, Tartu, Estonia
| | - Peeter Ross
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
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36
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Weitz E, Kleiboer A, van Straten A, Cuijpers P. The effects of psychotherapy for depression on anxiety symptoms: a meta-analysis. Psychol Med 2018; 48:2140-2152. [PMID: 29361995 DOI: 10.1017/s0033291717003622] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND More than half of patients who present with depressive disorders also have elevated comorbid anxiety symptoms. Given the high comorbidity between these disorders, it is important to understand the extent that psychotherapies for depression additionally ameliorate symptoms of anxiety. METHODS Systematic searches were conducted in PubMed, PSYCinfo, EMBASE, and the Cochrane Registry of Controlled Trials. Included studies were randomized controlled trials that compared psychotherapy compared with a control condition for the treatment of adults with a primary diagnosis or elevated symptoms of depression and that examined the effects of treatment on anxiety outcomes. Acute phase depression and anxiety (continuous measure) outcomes were extracted. Effect sizes were calculated by subtracting the average post-treatment scores of the psychotherapy group from the average post-treatment scores of the comparison group divided by the pooled standard deviation. RESULTS Fifty-two studies of varying quality met the inclusion criteria. Pooled effect sizes showed that anxiety outcomes were significantly lower in the psychotherapy conditions than in control conditions at post-treatment [g = 0.52; 95% confidence interval (CI) 0.44-0.60; NNT (numbers-needed-to-treat) = 3.50]. Moderate heterogeneity was observed (I2 = 55%, 95% CI 40-66). Bivariate metaregression analysis revealed a significant association between depression and anxiety effect sizes at post-treatment Longer-term follow-ups of up to 14 months post-baseline showed indications for a small lasting effect of psychotherapy on anxiety outcomes (g = 0.27). CONCLUSIONS This meta-analysis provides evidence that psychotherapy aimed at depression can also reduce anxiety symptoms in relation to control conditions.
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Affiliation(s)
- Erica Weitz
- Department of Clinical, Neuro and Developmental Psychology,EMGO Institute for Health and Care Research,Vrije Universiteit Amsterdam,Van der Boechorststraat 1, 1081 BT Amsterdam,The Netherlands
| | - Annet Kleiboer
- Department of Clinical, Neuro and Developmental Psychology,EMGO Institute for Health and Care Research,Vrije Universiteit Amsterdam,Van der Boechorststraat 1, 1081 BT Amsterdam,The Netherlands
| | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology,EMGO Institute for Health and Care Research,Vrije Universiteit Amsterdam,Van der Boechorststraat 1, 1081 BT Amsterdam,The Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology,EMGO Institute for Health and Care Research,Vrije Universiteit Amsterdam,Van der Boechorststraat 1, 1081 BT Amsterdam,The Netherlands
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37
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Sevilla-Llewellyn-Jones J, Santesteban-Echarri O, Pryor I, McGorry P, Alvarez-Jimenez M. Web-Based Mindfulness Interventions for Mental Health Treatment: Systematic Review and Meta-Analysis. JMIR Ment Health 2018; 5:e10278. [PMID: 30274963 PMCID: PMC6231788 DOI: 10.2196/10278] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Web-based mindfulness interventions are increasingly delivered through the internet to treat mental health conditions. OBJECTIVE The objective of this study was to determine the effectiveness of web-based mindfulness interventions in clinical mental health populations. Secondary aims were to explore the impact of study variables on the effectiveness of web-based mindfulness interventions. METHODS We performed a systematic review and meta-analysis of studies investigating the effects of web-based mindfulness interventions on clinical populations. RESULTS The search strategy yielded 12 eligible studies. Web-based mindfulness interventions were effective in reducing depression in the total clinical sample (n=656 g=-0.609, P=.004) and in the anxiety disorder subgroup (n=313, g=-0.651, P<.001), but not in the depression disorder subgroup (n=251, P=.18). Similarly, web-based mindfulness interventions significantly reduced anxiety in the total clinical sample (n=756, g=-0.433, P=.004) and the anxiety disorder subgroup (n=413, g=-0.719, P<.001), but not in the depression disorder group (n=251, g=-0.213, P=.28). Finally, web-based mindfulness interventions improved quality of life and functioning in the total sample (n=591, g=0.362, P=.02) in the anxiety disorder subgroup (n=370, g=0.550, P=.02) and mindfulness skills in the total clinical sample (n=251, g=0.724, P<.001). CONCLUSIONS Results support the effectiveness of web-based mindfulness interventions in reducing depression and anxiety and in enhancing quality of life and mindfulness skills, particularly in those with clinical anxiety. Results should be interpreted with caution given the high heterogeneity of web-based mindfulness interventions and the low number of studies included.
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Affiliation(s)
- Julia Sevilla-Llewellyn-Jones
- Institute of Psychiatry and Mental Health, Health Research Institute (IdISSC). Hospital Clínico San Carlos, Madrid, Spain.,Mental Health Department, Clinico Virgen de la Victoria Hospital, Málaga, Spain.,Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia.,Faculty of Psychology, Malaga University, Malaga, Spain
| | - Olga Santesteban-Echarri
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia.,Faculty of Health Sciences, Universidad Internacional de la Rioja (UNIR), Madrid, Spain
| | - Ingrid Pryor
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Patrick McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
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Titov N, Dear B, Nielssen O, Staples L, Hadjistavropoulos H, Nugent M, Adlam K, Nordgreen T, Bruvik KH, Hovland A, Repål A, Mathiasen K, Kraepelien M, Blom K, Svanborg C, Lindefors N, Kaldo V. ICBT in routine care: A descriptive analysis of successful clinics in five countries. Internet Interv 2018; 13:108-115. [PMID: 30206525 PMCID: PMC6112100 DOI: 10.1016/j.invent.2018.07.006] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Clinical trials have demonstrated the efficacy of internet delivered cognitive behaviour therapy (ICBT) for anxiety and depression. However, relatively little is known about the context, operations, and outcomes of ICBT when administered as part of routine care. This paper describes the setting, relationship to existing health services, procedures for referral, assessment, treatment, patients and outcomes of ICBT clinics in Sweden, Denmark, Norway, Canada and Australia. All five clinics provide services free or at low cost to patients. All have systems of governance to monitor quality of care, patient safety, therapist performance and data security. All five clinics include initial assessments by clinicians and between 10 and 20 min of therapist support during each week. Published reports of outcomes all demonstrate large clinical improvement, low rates of deterioration, and high levels of patient satisfaction. Services that require a face to face assessment treat smaller numbers of patients and have fewer patients from remote locations. The paper shows that therapist-guided ICBT can be a valuable part of mental health services for anxiety and depression. Important components of successful ICBT services are rigorous governance to maintain a high standard of clinical care, and the measurement and reporting of outcomes.
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Affiliation(s)
- Nickolai Titov
- MindSpot Clinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - Blake Dear
- MindSpot Clinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - Olav Nielssen
- MindSpot Clinic, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Lauren Staples
- MindSpot Clinic, Department of Psychology, Macquarie University, Sydney, Australia
| | | | - Marcie Nugent
- Department of Psychology, University of Regina, Regina, Canada
| | - Kelly Adlam
- Department of Psychology, University of Regina, Regina, Canada
| | - Tine Nordgreen
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Psychology, University of Bergen, Norway
| | | | - Anders Hovland
- Solli District Psychiatric Centre, Nesttun, Norway
- Department of Clinical Psychology, University of Bergen, Norway
| | | | - Kim Mathiasen
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Denmark
- Centre for Telepsychiatry, Mental Health Services of Southern Denmark, Denmark
| | - Martin Kraepelien
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Kerstin Blom
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Cecilia Svanborg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Nils Lindefors
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Viktor Kaldo
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Sweden
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
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Yang D, Hur JW, Kwak YB, Choi SW. A Systematic Review and Meta-Analysis of Applicability of Web-Based Interventions for Individuals with Depression and Quality of Life Impairment. Psychiatry Investig 2018; 15:759-766. [PMID: 30048585 PMCID: PMC6111215 DOI: 10.30773/pi.2018.03.15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/15/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this meta-analysis was to determine the applicability of web-based treatment programs for individuals with depression and quality of life impairments. METHODS We conducted database and manual searches using imprecise search-term strategy and inclusion criteria. Research published from 2005 to December 2015 was included in this study. Upon review, a total of 12 published papers on web-based intervention for individuals with depression were assessed eligible for this meta-analysis. Effect sizes were estimated for depression and quality of life. RESULTS The mean effect size of web-based treatment on depressive symptoms was 0.72. However, unlike the result showing medium to large effect size, the analysis on the quality of life did not yield adequate effects of web-based interventions. CONCLUSION Our results suggest robust benefits of employing web-based treatments for depressive symptoms. However, the adequacy of these relatively new intervention tools for individuals who suffer severe impairments of quality of life was found insufficient. The current study demonstrates the need to further develop web-based intervention techniques to improve overall functioning, as well as the clinical symptoms of patients with mental disorders.
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Affiliation(s)
- Danbi Yang
- Department of Psychology, Duksung Women's University, Seoul, Republic of Korea
| | - Ji-Won Hur
- Department of Psychology, Chung-Ang University, Seoul, Republic of Korea
| | - Yoo Bin Kwak
- Department of Brain and Cognitive Sciences, Seoul National University, Seoul, Republic of Korea
| | - Sung-Won Choi
- Department of Psychology, Duksung Women's University, Seoul, Republic of Korea
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40
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Kraepelien M, Mattsson S, Hedman-Lagerlöf E, Petersson IF, Forsell Y, Lindefors N, Kaldo V. Cost-effectiveness of internet-based cognitive-behavioural therapy and physical exercise for depression. BJPsych Open 2018; 4:265-273. [PMID: 30057780 PMCID: PMC6060490 DOI: 10.1192/bjo.2018.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 05/21/2018] [Accepted: 06/06/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Both internet-based cognitive-behavioural therapy (ICBT) and physical exercise are alternatives to treatment as usual (TAU) in managing mild to moderate depression in primary care. AIMS To determine the cost-effectiveness of ICBT and physical exercise compared with TAU in primary care. METHOD Economic evaluation of a randomised controlled trial (N = 945) in Sweden. Costs were estimated by a service use questionnaire and used together with the effects on quality-adjusted life-years (QALYs). The primary 3-month healthcare provider perspective in primary care was complemented by a 1-year societal perspective. RESULTS The primary analysis showed that incremental cost per QALY gain was €8817 for ICBT and €14 571 for physical exercise compared with TAU. At the established willingness-to-pay threshold of €21 536 (£20 000) per QALY, the probability of ICBT being cost-effective is 90%, and for physical exercise is 76%, compared with TAU. CONCLUSIONS From a primary care perspective, both ICBT and physical exercise for depression are likely to be cost-effective compared with TAU. DECLARATION OF INTEREST None.
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Affiliation(s)
- Martin Kraepelien
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Sweden
| | - Simon Mattsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden
| | - Erik Hedman-Lagerlöf
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Sweden
| | - Ingemar F Petersson
- Department of Clinical Sciences, Department of Orthopaedics, Lund University, Sweden
| | - Yvonne Forsell
- Department of Public Health Sciences, Section for Epidemiology and Public Health Intervention Research, Karolinska Institutet, Sweden
| | - Nils Lindefors
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Sweden
| | - Viktor Kaldo
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Sweden; Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Sweden
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Topooco N, Berg M, Johansson S, Liljethörn L, Radvogin E, Vlaescu G, Nordgren LB, Zetterqvist M, Andersson G. Chat- and internet-based cognitive-behavioural therapy in treatment of adolescent depression: randomised controlled trial. BJPsych Open 2018; 4:199-207. [PMID: 29988969 PMCID: PMC6034465 DOI: 10.1192/bjo.2018.18] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/07/2018] [Accepted: 03/26/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Depression is a major contributor to the burden of disease in the adolescent population. Internet-based interventions can increase access to treatment. AIMS To evaluate the efficacy of internet-based cognitive-behavioural therapy (iCBT), including therapist chat communication, in treatment of adolescent depression. METHOD Seventy adolescents, 15-19 years of age and presenting with depressive symptoms, were randomised to iCBT or attention control. The primary outcome was the Beck Depression Inventory II (BDI-II). RESULTS Significant reductions in depressive symptoms were found, favouring iCBT over the control condition (F(1,67) = 6.18, P < 0.05). The between-group effect size was Cohen's d = 0.71 (95% CI 0.22-1.19). A significantly higher proportion of iCBT participants (42.4%) than controls (13.5%) showed a 50% decrease in BDI-II score post-treatment (P < 0.01). The improvement for the iCBT group was maintained at 6 months. CONCLUSIONS The intervention appears to effectively reduce symptoms of depression in adolescents and may be helpful in overcoming barriers to care among young people. DECLARATION OF INTEREST N.T. and G.A. designed the programme. N.T. authored the treatment material. The web platform used for treatment is owned by Linköping University and run on a non-for-profit basis. None of the authors receives any income from the programme.
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Affiliation(s)
- Naira Topooco
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Matilda Berg
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Sofie Johansson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Lina Liljethörn
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Ella Radvogin
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - George Vlaescu
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Lise Bergman Nordgren
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Maria Zetterqvist
- Centre for Social and Affective Neuroscience, Department of Clinical and Experimental Medicine and Child and Adolescent Psychiatry, Linköping University, Linköping, Sweden
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Karyotaki E, Ebert DD, Donkin L, Riper H, Twisk J, Burger S, Rozental A, Lange A, Williams AD, Zarski AC, Geraedts A, van Straten A, Kleiboer A, Meyer B, Ünlü Ince BB, Buntrock C, Lehr D, Snoek FJ, Andrews G, Andersson G, Choi I, Ruwaard J, Klein JP, Newby JM, Schröder J, Laferton JAC, Van Bastelaar K, Imamura K, Vernmark K, Boß L, Sheeber LB, Kivi M, Berking M, Titov N, Carlbring P, Johansson R, Kenter R, Perini S, Moritz S, Nobis S, Berger T, Kaldo V, Forsell Y, Lindefors N, Kraepelien M, Björkelund C, Kawakami N, Cuijpers P. Do guided internet-based interventions result in clinically relevant changes for patients with depression? An individual participant data meta-analysis. Clin Psychol Rev 2018; 63:80-92. [PMID: 29940401 DOI: 10.1016/j.cpr.2018.06.007] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 06/06/2018] [Accepted: 06/14/2018] [Indexed: 12/22/2022]
Abstract
Little is known about clinically relevant changes in guided Internet-based interventions for depression. Moreover, methodological and power limitations preclude the identification of patients' groups that may benefit more from these interventions. This study aimed to investigate response rates, remission rates, and their moderators in randomized controlled trials (RCTs) comparing the effect of guided Internet-based interventions for adult depression to control groups using an individual patient data meta-analysis approach. Literature searches in PubMed, Embase, PsycINFO and Cochrane Library resulted in 13,384 abstracts from database inception to January 1, 2016. Twenty-four RCTs (4889 participants) comparing a guided Internet-based intervention with a control group contributed data to the analysis. Missing data were multiply imputed. To examine treatment outcome on response and remission, mixed-effects models with participants nested within studies were used. Response and remission rates were calculated using the Reliable Change Index. The intervention group obtained significantly higher response rates (OR = 2.49, 95% CI 2.17-2.85) and remission rates compared to controls (OR = 2.41, 95% CI 2.07-2.79). The moderator analysis indicated that older participants (OR = 1.01) and native-born participants (1.66) were more likely to respond to treatment compared to younger participants and ethnic minorities respectively. Age (OR = 1.01) and ethnicity (1.73) also moderated the effects of treatment on remission.Moreover, adults with more severe depressive symptoms at baseline were more likely to remit after receiving internet-based treatment (OR = 1.19). Guided Internet-based interventions lead to substantial positive treatment effects on treatment response and remission at post-treatment. Thus, such interventions may complement existing services for depression and potentially reduce the gap between the need and provision of evidence-based treatments.
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Affiliation(s)
- Eirini Karyotaki
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands.
| | - David Daniel Ebert
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Liesje Donkin
- The Brain and Mind Research Institute, University of Sydney, NSW 2050, Australia
| | - Heleen Riper
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
| | - Jos Twisk
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Amsterdam, Amsterdam, the Netherlands
| | - Simone Burger
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
| | - Alexander Rozental
- Institute of Child Health, University College London, United Kingdom; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Alfred Lange
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Alishia D Williams
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
| | - Anna Carlotta Zarski
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | | | - Annemieke van Straten
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
| | - Annet Kleiboer
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
| | - Björn Meyer
- Research Department, Gaia AG, Hamburg, Germany; Department of Psychology, City, University of London, London, United Kingdom
| | | | - Claudia Buntrock
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Dirk Lehr
- Institute of Psychology, Leuphana University Lüneburg, Germany
| | - Frank J Snoek
- Department of Medical Psychology, VU Medical Center, Academic Medical Center, Public Health Research institute, Amsterdam, the Netherlands
| | - Gavin Andrews
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Gerhard Andersson
- Department of Behavioral Sciences and Learning, Linköping University, Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institute for Disability Research, Stockholm, Sweden
| | - Isabella Choi
- Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Jeroen Ruwaard
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
| | - Jan Philipp Klein
- Department of Psychiatry and Psychotherapy, Luebeck University, Luebeck, Germany
| | - Jill M Newby
- Clinical Research Unit for Anxiety and Depression, School of Psychiatry, University of New South Wales at St Vincent's Hospital, Darlinghurst, NSW, Australia; The MRC Cognition and Brain Sciences Unit, Cambridge, United Kingdom; School of Psychology, the University of New South Wales, Sydney, Australia
| | - Johanna Schröder
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institute for Sex Research and Forensic Psychiatry, Hamburg, Germany
| | - Johannes A C Laferton
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Kim Van Bastelaar
- Department of Medical Psychology, VU Medical Center, Amsterdam, the Netherlands
| | - Kotaro Imamura
- Department of Mental Health, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyō-ku, Tokyo, Japan
| | - Kristofer Vernmark
- Department of Behavioural Sciences and Learning, Linkoping University, Linkoping, Sweden
| | - Leif Boß
- Institute of Psychology, Leuphana University Lüneburg, Germany
| | | | - Marie Kivi
- Department of Psychology, University of Gothenburg, Göteborg, Sweden
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Nickolai Titov
- MindSpot Clinic and eCentreClinic, Department of Psychology, Macquarie University, Australia
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden; Department of Psychology, University of Southern Denmark, Denmark
| | - Robert Johansson
- Department of Behavioral Sciences and Learning, Linköping University, and Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Robin Kenter
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Sarah Perini
- Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Steffen Moritz
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
| | - Stephanie Nobis
- Division of Online Health Training, Innovation Incubator, Leuphana University Lüneburg, Germany
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Viktor Kaldo
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Yvonne Forsell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Nils Lindefors
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Martin Kraepelien
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Cecilia Björkelund
- Department of Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Norito Kawakami
- Department of Mental Health, School of Public Health, Graduate School of Medicine, The University of Tokyo, Bunkyō-ku, Tokyo, Japan
| | - Pim Cuijpers
- Department of Clinical Psychology, Amsterdam Public Health research institute, VU, Amsterdam, the Netherlands
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Holst A, Björkelund C, Metsini A, Madsen JH, Hange D, Petersson ELL, Eriksson MCM, Kivi M, Andersson PÅÅ, Svensson M. Cost-effectiveness analysis of internet-mediated cognitive behavioural therapy for depression in the primary care setting: results based on a controlled trial. BMJ Open 2018; 8:e019716. [PMID: 29903785 PMCID: PMC6009451 DOI: 10.1136/bmjopen-2017-019716] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To perform a cost-effectiveness analysis of a randomised controlled trial of internet-mediated cognitive behavioural therapy (ICBT) compared with treatment as usual (TaU) for patients with mild to moderate depression in the Swedish primary care setting. In particular, the objective was to assess from a healthcare and societal perspective the incremental cost-effectiveness ratio (ICER) of ICBT versus TaU at 12 months follow-up. DESIGN A cost-effectiveness analysis alongside a pragmatic effectiveness trial. SETTING Sixteen primary care centres (PCCs) in south-west Sweden. PARTICIPANTS Ninety patients diagnosed with mild to moderate depression at the PCCs. MAIN OUTCOME MEASURE ICERs calculated as (CostICBT-CostTaU)/(Health outcomeICBT-Health outcomeTaU)=ΔCost/ΔHealth outcomes, the health outcomes being changes in the Beck Depression Inventory-II (BDI-II) score and quality-adjusted life-years (QALYs). RESULTS The total cost per patient for ICBT was 4044 Swedish kronor (SEK) (€426) (healthcare perspective) and SEK47 679 (€5028) (societal perspective). The total cost per patient for TaU was SEK4434 (€468) and SEK50 343 (€5308). In both groups, the largest cost was associated with productivity loss. The differences in cost per patient were not statistically significant. The mean reduction in BDI-II score was 13.4 and 13.8 units in the ICBT and TaU groups, respectively. The mean QALYs per patient was 0.74 and 0.79 in the ICBT and TaU groups, respectively. The differences in BDI-II score reduction and mean QALYs were not statistically significant. The uncertainty of the study estimates when assessed by bootstrapping indicated that no firm conclusion could be drawn as to whether ICBT treatment compared with TaU was the most cost-effective use of resources. CONCLUSIONS ICBT was regarded to be as cost-effective as TaU as costs, health outcomes and cost-effectiveness were similar for ICBT and TaU, both from a healthcare and societal perspective. TRIAL REGISTRATION NUMBER ID NR 30511.
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Affiliation(s)
- Anna Holst
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | | | - Dominique Hange
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Eva-Lisa L Petersson
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - Maria CM Eriksson
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marie Kivi
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Per-Åke Å Andersson
- Department of Economics, School of Business, Economics and Law at University of Gothenburg, Gothenburg, Sweden
| | - Mikael Svensson
- Department of Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Görges F, Oehler C, von Hirschhausen E, Hegerl U, Rummel-Kluge C. GET.HAPPY - Acceptance of an internet-based self-management positive psychology intervention for adult primary care patients with mild and moderate depression or dysthymia: A pilot study. Internet Interv 2018; 12:26-35. [PMID: 30135766 PMCID: PMC6096332 DOI: 10.1016/j.invent.2018.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION A growing number of internet interventions have been shown to help in alleviating symptoms of depression. So far, only little research has focused on other methods than CBT. The present study aimed to investigate the level of satisfaction with a positive psychology online training among patients with mild and moderate depression or dysthymia. Secondary outcome measures included changes in symptom severity, health related quality of life, and negative effects. METHODS A total of 81 participants were allocated to the intervention. They were asked to complete online questionnaires and were called by one of the study psychologists at baseline, at post-treatment, and at follow-up (3 months after completion of the intervention). Shorter questionnaires were administered after each module. RESULTS Overall satisfaction was promising. While participants seemed to be very satisfied with many aspects of the program itself, they were slightly less satisfied with its impact on the problems they sought to solve. Overall, negative effects attributed to the program were small with one exception. At post-treatment, 22.6% of the participants felt that they or their problems were not taken seriously by the program. Symptom severity decreased over time with mild to moderate effect sizes. There was a moderate increase in satisfaction with mental health at both post-treatment and follow-up. CONCLUSIONS The online program investigated here may be a useful resource-oriented addition to the standard treatment of depression.
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Affiliation(s)
- Frauke Görges
- Depression Research Centre, German Depression Foundation, Semmelweisstr. 10, 04103 Leipzig, Germany
| | - Caroline Oehler
- Depression Research Centre, German Depression Foundation, Semmelweisstr. 10, 04103 Leipzig, Germany
| | | | - Ulrich Hegerl
- Depression Research Centre, German Depression Foundation, Semmelweisstr. 10, 04103 Leipzig, Germany
- Department of Psychiatry and Psychotherapy, Leipzig University, Semmelweisstr. 10, 04103 Leipzig, Germany
| | - Christine Rummel-Kluge
- Depression Research Centre, German Depression Foundation, Semmelweisstr. 10, 04103 Leipzig, Germany
- Department of Psychiatry and Psychotherapy, Leipzig University, Semmelweisstr. 10, 04103 Leipzig, Germany
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O'Connor M, Munnelly A, Whelan R, McHugh L. The Efficacy and Acceptability of Third-Wave Behavioral and Cognitive eHealth Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Behav Ther 2018; 49:459-475. [PMID: 29704973 DOI: 10.1016/j.beth.2017.07.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/12/2017] [Accepted: 07/21/2017] [Indexed: 01/12/2023]
Abstract
eHealth is an innovative method of delivering therapeutic content with the potential to improve access to third-wave behaviural and cognitive therapies. This systematic review and meta-analysis aimed to determine the efficacy and acceptability of third-wave eHealth treatments in improving mental health outcomes. A comprehensive search of electronic bibliographic databases including PubMed, PsycINFO, Web of Science, and CENTRAL was conducted to identify randomized controlled trials of third-wave treatments in which eHealth was the main component. Twenty-one studies were included in the review. Meta-analyses revealed that third-wave eHealth significantly outperformed inactive control conditions in improving anxiety, depression, and quality-of-life outcomes and active control conditions in alleviating anxiety and depression with small to medium effect sizes. No statistically significant differences were found relative to comparison interventions. Findings from a narrative synthesis of participant evaluation outcomes and meta-analysis of participant attrition rates provided preliminary support for the acceptability of third-wave eHealth. Third-wave eHealth treatments are efficacious in improving mental health outcomes including anxiety, depression, and quality of life, but not more so than comparison interventions. Preliminary evidence from indices of participant evaluation and attrition rates supports the acceptability of these treatments.
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Affiliation(s)
| | | | - Robert Whelan
- Trinity Institute of Neurosciences, Trinity College Dublin, The University of Dublin
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Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, Newby JM. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. J Anxiety Disord 2018; 55:70-78. [PMID: 29422409 DOI: 10.1016/j.janxdis.2018.01.001] [Citation(s) in RCA: 498] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/16/2017] [Accepted: 01/03/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND A 2010 meta-analysis of internet-delivered CBT (iCBT) RCTs argued 'computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care' without data on effectiveness or practicality in routine practice. METHODS Databases, reviews and meta-analyses were searched for randomised controlled trials of cCBT or iCBT versus a control group (care as usual, waitlist, information control, psychological placebo, pill placebo, etc.) in people who met diagnostic criteria for major depression, panic disorder, social anxiety disorder or generalised anxiety disorder. Number randomised, superiority of treatment versus control (Hedges'g) on primary outcome measure, length of follow-up, follow up outcome, patient adherence and satisfaction/harm were extracted; risk of bias was assessed. A search for studies on effectiveness of iCBT in clinical practice was conducted. RESULTS 64 trials were identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-with good acceptability. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials. LIMITATIONS Studies variably measured changes in quality of life and disability, and the lack of comparisons with medications weakens the field. CONCLUSIONS The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical health care.
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Affiliation(s)
- G Andrews
- School of Psychiatry, University of New South Wales, Sydney Australia.
| | - A Basu
- University of New South Wales, Sydney, Australia
| | - P Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, Vrije Universiteit and VU Medical Center Amsterdam, The Netherlands
| | - M G Craske
- Department of Psychology, University of California, Los Angeles, United States
| | - P McEvoy
- School of Psychology and Speech Pathology, Curtin University, Perth, Australia; Centre for Clinical Interventions, Perth, Australia
| | - C L English
- St George's University of London, United Kingdom
| | - J M Newby
- School of Psychology, University of New South Wales, Sydney Australia
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Ahern E, Kinsella S, Semkovska M. Clinical efficacy and economic evaluation of online cognitive behavioral therapy for major depressive disorder: a systematic review and meta-analysis. Expert Rev Pharmacoecon Outcomes Res 2018; 18:25-41. [PMID: 29145746 DOI: 10.1080/14737167.2018.1407245] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Leading cause of disability worldwide, depression is the most prevalent mental disorder with growing societal costs. As mental health services demand often outweighs provision, accessible treatment options are needed. Our systematic review and meta-analysis evaluated the clinical efficacy and economic evidence for the use of online cognitive behavioral therapy (oCBT) as an accessible treatment solution for depression. AREAS COVERED Electronic databases were searched for controlled trials published between 2006 and 2016. Of the reviewed 3,324 studies, 29 met the criteria for inclusion in the efficacy meta-analysis. The systematic review identified five oCBT economic evaluations. Therapist-supported oCBT was equivalent to face-to-face CBT at improving depressive symptoms and superior to treatment-as-usual, waitlist control, and attention control. Depression severity, number of sessions, or support did not affect efficacy. From a healthcare provider perspective, oCBT tended to show greater costs with greater benefits in the short term, relative to comparator treatments. EXPERT COMMENTARY Although efficacious, further economic evidence is required to support the provision of oCBT as a cost-effective treatment for depression. Economic evaluations that incorporate a societal perspective will better account for direct and indirect treatment costs. Nevertheless, oCBT shows promise of effectively improving depressive symptoms, considering limited mental healthcare resources.
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Affiliation(s)
- Elayne Ahern
- a Department of Psychology , University of Limerick , Limerick , Ireland
- b Department of Economics , Kemmy Business School, University of Limerick , Limerick , Ireland
| | - Stephen Kinsella
- b Department of Economics , Kemmy Business School, University of Limerick , Limerick , Ireland
| | - Maria Semkovska
- a Department of Psychology , University of Limerick , Limerick , Ireland
- c Health Research Institute , University of Limerick , Limerick , Ireland
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48
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Massoudi B, Blanker MH, van Valen E, Wouters H, Bockting CLH, Burger H. Blended care vs. usual care in the treatment of depressive symptoms and disorders in general practice [BLENDING]: study protocol of a non-inferiority randomized trial. BMC Psychiatry 2017; 17:218. [PMID: 28610561 PMCID: PMC5470276 DOI: 10.1186/s12888-017-1376-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/01/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The majority of patients with depressive disorders are treated by general practitioners (GPs) and are prescribed antidepressant medication. Patients prefer psychological treatments but they are under-used, mainly due to time constraints and limited accessibility. A promising approach to deliver psychological treatment is blended care, i.e. guided online treatment. However, the cost-effectiveness of blended care formatted as an online psychological treatment supported by the patients' own GP or general practice mental health worker (MHW) in routine primary care is unknown. We aim to demonstrate non-inferiority of blended care compared with usual care in patients with depressive symptoms or a depressive disorder in general practice. Additionally, we will explore the real-time course over the day of emotions and affect, and events within individuals during treatment. METHODS This is a pragmatic non-inferiority trial including 300 patients with depressive symptoms, recruited by collaborating GPs and MHWs. After inclusion, participants are randomized to either blended care or usual care in routine general practice. Blended care consists of the 'Act and Feel' treatment: an eight-week web-based program based on behavioral activation with integrated monitoring of depressive symptomatology and automatized feedback. GPs or their MHWs coach the participants through regular face-to-face or telephonic consultations with at least three sessions. Depressive symptomatology, health status, functional impairment, treatment satisfaction, daily activities and resource use are assessed during a follow-up period of 12 months. During treatment, real-time fluctuations in emotions and affect, and daily events will be rated using ecological momentary assessment. The primary outcome is the reduction of depressive symptoms from baseline to three months follow-up. We will conduct intention-to-treat analyses and supplementary per-protocol analyses. DISCUSSION This trial will show whether blended care might be an appropriate treatment strategy for patients with depressive symptoms and depressive disorder in general practice. TRIAL REGISTRATION Netherlands Trial Register: NTR4757; 25 August 2014. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4757 . (Archived by WebCite® at http://www.webcitation.org/6mnXNMGef ).
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Affiliation(s)
- Btissame Massoudi
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD, Groningen, the Netherlands.
| | - Marco H. Blanker
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, the Netherlands
| | - Evelien van Valen
- 0000000120346234grid.5477.1Department of Clinical Psychology, University of Utrecht, Utrecht, The Netherlands
| | - Hans Wouters
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, the Netherlands
| | - Claudi L. H. Bockting
- 0000000120346234grid.5477.1Department of Clinical Psychology, University of Utrecht, Utrecht, The Netherlands ,0000 0004 0407 1981grid.4830.fDepartment of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
| | - Huibert Burger
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, the Netherlands
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Eriksson MCM, Kivi M, Hange D, Petersson EL, Ariai N, Häggblad P, Ågren H, Spak F, Lindblad U, Johansson B, Björkelund C. Long-term effects of Internet-delivered cognitive behavioral therapy for depression in primary care - the PRIM-NET controlled trial. Scand J Prim Health Care 2017; 35:126-136. [PMID: 28585868 PMCID: PMC5499312 DOI: 10.1080/02813432.2017.1333299] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/26/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Internet-delivered cognitive behavioral therapy (ICBT) is recommended as an efficient treatment alternative for depression in primary care. However, only few previous studies have been conducted at primary care centers (PCCs). We evaluated long-term effects of ICBT treatment for depression compared to treatment as usual (TAU) in primary care settings. DESIGN Randomized controlled trial. SETTING Patients were enrolled at16 PCCs in south-west Sweden. PARTICIPANTS Patients attending PCCs and diagnosed with depression (n = 90). INTERVENTIONS Patients were assessed by a primary care psychologist/psychotherapist and randomized to ICBT or TAU. The ICBT included an ICBT program consisting of seven modules and weekly therapist e-mail or telephone support during the 3-month treatment period. MAIN OUTCOME MEASURES Questionnaires on depressive symptoms (BDI-II), quality of life (EQ-5D) and psychological distress (GHQ-12) were administered at baseline, with follow-ups at 3, 6 and 12 months. Antidepressants and sedatives use, sick leave and PCC contacts were registered. RESULTS Intra-individual change in depressive symptoms did not differ between the ICBT group and the TAU group during the treatment period or across the follow-up periods. At 3-month follow-up, significantly fewer patients in ICBT were on antidepressants. However, the difference leveled out at later follow-ups. There were no differences between the groups concerning psychological distress, sick leave or quality of life, except for a larger improvement in quality of life in the TAU group during the 0- to 6-month period. CONCLUSIONS ICBT with weekly minimal therapist support in primary care can be equally effective as TAU among depressed patients also over a 12-month period. CLINICAL TRIAL REGISTRATION The trial was registered in the Swedish Registry, researchweb.org, ID number 30511.
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Affiliation(s)
- Maria C. M. Eriksson
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marie Kivi
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Dominique Hange
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva-Lisa Petersson
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Gothenburg, Sweden
| | - Nashmil Ariai
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Hans Ågren
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Spak
- Department of Epidemiology and Social Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ulf Lindblad
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Boo Johansson
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Department of Primary Health Care/Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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50
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Wahle F, Bollhalder L, Kowatsch T, Fleisch E. Toward the Design of Evidence-Based Mental Health Information Systems for People With Depression: A Systematic Literature Review and Meta-Analysis. J Med Internet Res 2017; 19:e191. [PMID: 28566267 PMCID: PMC5471345 DOI: 10.2196/jmir.7381] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 03/10/2017] [Accepted: 04/06/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Existing research postulates a variety of components that show an impact on utilization of technology-mediated mental health information systems (MHIS) and treatment outcome. Although researchers assessed the effect of isolated design elements on the results of Web-based interventions and the associations between symptom reduction and use of components across computer and mobile phone platforms, there remains uncertainty with regard to which components of technology-mediated interventions for mental health exert the greatest therapeutic gain. Until now, no studies have presented results on the therapeutic benefit associated with specific service components of technology-mediated MHIS for depression. OBJECTIVE This systematic review aims at identifying components of technology-mediated MHIS for patients with depression. Consequently, all randomized controlled trials comparing technology-mediated treatments for depression to either waiting-list control, treatment as usual, or any other form of treatment for depression were reviewed. Updating prior reviews, this study aims to (1) assess the effectiveness of technology-supported interventions for the treatment of depression and (2) add to the debate on what components in technology-mediated MHIS for the treatment of depression should be standard of care. METHODS Systematic searches in MEDLINE, PsycINFO, and the Cochrane Library were conducted. Effect sizes for each comparison between a technology-enabled intervention and a control condition were computed using the standard mean difference (SMD). Chi-square tests were used to test for heterogeneity. Using subgroup analysis, potential sources of heterogeneity were analyzed. Publication bias was examined using visual inspection of funnel plots and Begg's test. Qualitative data analysis was also used. In an explorative approach, a list of relevant components was extracted from the body of literature by consensus between two researchers. RESULTS Of 6387 studies initially identified, 45 met all inclusion criteria. Programs analyzed showed a significant trend toward reduced depressive symptoms (SMD -0.58, 95% CI -0.71 to -0.45, P<.001). Heterogeneity was large (I2≥76). A total of 15 components were identified. CONCLUSIONS Technology-mediated MHIS for the treatment of depression has a consistent positive overall effect compared to controls. A total of 15 components have been identified. Further studies are needed to quantify the impact of individual components on treatment effects and to identify further components that are relevant for the design of future technology-mediated interventions for the treatment of depression and other mental disorders.
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Affiliation(s)
- Fabian Wahle
- Center for Digital Health Interventions, Department of Management, Technology and Economics, ETH Zürich, Zürich, Switzerland
| | - Lea Bollhalder
- Institute of Technology Management, University of St Gallen, St Gallen, Switzerland
| | - Tobias Kowatsch
- Center for Digital Health Interventions, Institute of Technology Management, University of St Gallen, St Gallen, Switzerland
| | - Elgar Fleisch
- Institute of Technology Management, University of St Gallen, St Gallen, Switzerland
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