Adherence predictors in an Internet-based Intervention program for depression

Adherence to Online Interventions for Family Caregivers of People With Dementia: A Meta-Analysis and Systematic Review

OBJECTIVE

Online interventions hold promise in supporting the well-being of family caregivers and enhancing the quality of care they provide for individuals with long-term or chronic conditions. However, dropout rates from support programs among specific groups of caregivers, such as caregivers of people with dementia, pose a challenge. Focused reviews are needed to provide more accurate insights and estimates in this specific research area.

METHODS

A meta-analysis of dropout rates from available online interventions for family caregivers of people with dementia was conducted to assess treatment acceptability. A systematic search yielded 18 studies involving 1,215 caregivers.

RESULTS

The overall pooled dropout rate was 18.4%, with notable heterogeneity indicating varied intervention adherence. Interventions incorporating human contact, interactive features, and personalization strategies for specific types and stages of dementia predicted significantly lower dropout rates. Methodological assessment revealed variability in study quality.

CONCLUSION

Findings support the effectiveness of social support, personalization strategies, and co-design in enhancing intervention adherence among dementia family caregivers. Further research is needed to explore factors influencing dropout rates and conduct robust trials to refine the implementation of future interventions.

Bridging the adherence gap in internet interventions: A randomized controlled trial study protocol investigating context-specific self-efficacy

Low adherence in self-guided internet interventions is linked to poorer outcomes. Although some predictors of adherence have been identified, few are modifiable for widespread application. One personal variable with the potential to increase adherence in internet interventions is context-specific self-efficacy. This protocol outlines a randomized controlled trial design, divided into two phases. In Phase 1 (students, N = 216), participants will complete a self-efficacy-enhancing exercise, which will be compared to a waitlist control group to test its effectiveness in increasing internet intervention adherence self-efficacy. Phase 2 will be the main two-arm trial, where all participants (medical students, N = 952) will undergo an internet intervention called Med-Stress Student. In the experimental group, the program will be preceded by the self-efficacy-enhancing exercise developed in Phase 1. We anticipate that participants in the experimental group will show higher adherence (primary outcome) to the intervention and greater improvement in intervention outcomes (secondary outcomes i.e., lower stress and higher work engagement) at posttest, as well as at six-month and one-year follow-ups. If effective, enhancing context-specific self-efficacy could be recommended before any internet intervention as a relatively simple way to boost participants' adherence.

Predictors of nonresponse to treatment and low adherence to internet-based cognitive behavioral therapy in depressed/anxious women facing the couple's fertility problems: a secondary analysis of a randomized control trial

BACKGROUND

The study aimed to examine the predictors of treatment nonresponse and low adherence to Internet-based cognitive behavioral therapy and face-to-face therapy for treating depression and anxiety in women facing the couple's fertility problems.

METHODS

This is a secondary analysis based on a previous randomized controlled trial including 152 depressed/anxious women facing the couple's fertility problems. The study defines low adherence as receiving less than 4 sessions (out of 8 sessions). Nonresponse to treatment refers to a < 50% reduction in the anxiety and depression total scores.

RESULTS

A high level of anxiety/depression score before psychotherapy increases the risk of nonresponse to both Internet-based and face-to-face psychotherapies by 1.4 to 2 times in women facing the couple's fertility problems after the treatment and in the 6-month follow-up. However, 4 factors, including diagnosis of mixed anxiety and depression, low education level, long marriage duration, and infertility caused by mixed female/male factors, reduced the risk of nonresponse to psychotherapies.

CONCLUSION

Women facing the couple's fertility problems with high depression and anxiety scores are at risk of poor prognosis in response to psychotherapy. Psychologists and healthcare providers of infertility centers should pay more attention to the timely identification and referral of depressed/anxious patients to psychologists.

Usage of unguided, guided, and blended care for depression offered in routine clinical care: Lessons learned

Introduction

Internet-delivered psychotherapy is often considered to be a promising way to extend mental healthcare services around the world. Research findings that have emerged over the past two decades have strengthened this claim. However, very little is known about the usage of internet-delivered psychotherapy in real-life circumstances.

Methods

The current study explored the real-life usage of depressiehulp.be, a publicly available online platform for depression that offers pure self-help, online guided self-help, and blended treatment for depression in Flanders, Belgium, using data collected from 2656 participants between May 2018 and May 2022.

Results

Both duration of engagement with the online platform and number of exercises completed increased with increasing levels of therapist guidance. Findings also showed a particular pattern of engagement for each of the online treatments. Overall, participants completed most exercises during the first days of treatment. However, participants using pure online self-help showed the fastest decrease of engagement over time, with most dropping out after completing a few exercises, and more than half of all participants who enrolled in the self-help programme did not even begin the programme. In both guided and blended treatment, participants tended to show higher levels of engagement with the online platform. In each treatment modality, a relatively small but notable group of participants showed high levels of engagement. There was no relationship between severity of depression and duration of engagement.

Conclusions

The current study demonstrates the importance of therapist support in online interventions and offers additional insights into how, and to what extent, online platforms are used. Future research should explore clinical impact and policy implications.

A pilot test of Internet-delivered brief interactive training sessions for depression: Evaluating dropout, uptake, adherence, and outcome

OBJECTIVE

Uptake, adherence, and dropout rates for Internet-based programs for depression are in need of improvement. Excessive user burden (eg, heavy content, extended duration) may undermine engagement and precipitate dropout. To address this problem, an alternative format was proposed: Brief Interactive Training Sessions (BITS). BITS target a narrow behavioral health skill and require 3-4 hours to complete. A depression-focused version of BITS that provides training in cognitive distortion/restructuring was tested.

PARTICIPANTS

Fifty-two depressed college students were randomly assigned to BITS or to a wait-list.

METHODS

Students competed pre-and post-test (7 week) assessments of depression and cognitive distortions.

RESULTS

Uptake rate was 83%. Among study completers, adherence was 96%. The dropout rate did not improve. Compared to the control group, the experimental group reported a significant reduction in depression and in cognitive distortions.

CONCLUSIONS

The BITS format is a promising vehicle for improving uptake and adherence while achieving positive clinical outcomes.

How does social media use influence the mental health of pancreatic cancer patients: a chain mediating effect of online social support and psychological resilience

Background

Pancreatic cancer is an extremely malignant disease that poses a serious threat to the mental health of patients. Many cancer patients now use social media for online social support. However, the impact of social media on mental health is currently inconsistent in the academic community. Therefore, this study aimed to examine the mediating effects of online social support and psychological resilience in the relationship between social media use and mental health of pancreatic cancer patients.

Methods

Four hundred and twenty-five valid questionnaires were collected through convenience sampling. All data were processed using SPSS 26.0 and AMOS 26.0. We examine the influence relationships among latent variables by constructing a structural equation model. Then SPSS Process Macro was used to test the chain mediating effect of the model.

Results

The results showed that (1) anxiety situations occurred in 22.2% of participants (N = 94), while the incidence of depression was 20.2% (N = 86). (2) Social media use positively influenced online social support (β = 0.990, p < 0.001), psychological resilience (β = 0.504, p < 0.001), and mental health (β = 0.330, p < 0.001); online social support positively influenced psychological resilience (β = 0.535, p < 0.001) and mental health (β = 0.354, p < 0.001); psychological resilience significantly and positively influenced mental health (β = 0.243, p < 0.001). (3) The chain mediating effect of online social support and psychological resilience was significant at 0.253 with a confidence interval of [0.178, 0.340].

Conclusion

Pancreatic cancer patients in China are exposed to a high burden of anxiety and depression, which requires urgent attention. Meanwhile, online social support and psychological resilience played a chain mediating role between social media use and mental health (anxiety and depression), and our results provide new insights and ways to support the mental health improvement of pancreatic cancer patients.

Effectiveness and implementation of an online intervention (MINDxYOU) for reducing stress and promote mental health among healthcare workers in Spain: a study protocol for a stepped-wedge cluster randomized trial

BACKGROUND

The World Health Organization has formally recognized that healthcare professionals are at risk of developing mental health problems; finding ways to reduce their stress is mandatory to improve both their quality of life and, indirectly, their job performance. In recent years, particularly since the COVID-19 pandemic outbreak, there has been a proliferation of online interventions with promising results. The purpose of the present study is twofold: to test the effectiveness of an online, self-guided intervention, MINDxYOU, to reduce the stress levels of healthcare workers; and to conduct an implementation study of this intervention. Additionally, an economic evaluation of the intervention will be conducted.

METHODS

The current study has a hybrid effectiveness-implementation type 2 design. A stepped wedge cluster randomized trial design will be used, with a cohort of 180 healthcare workers recruited in two Spanish provinces (Malaga and Zaragoza). The recruitment stage will commence in October 2022. Frontline health workers who provide direct care to people in a hospital, primary care center, or nursing home setting in both regions will participate. The effectiveness of the intervention will be studied, with perceived stress as the main outcome (Perceived Stress Scale), while other psychopathological symptoms and process variables (e.g., mindfulness, compassion, resilience, and psychological flexibility) will be also assessed as secondary outcomes. The implementation study will include analysis of feasibility, acceptability, adoption, appropriateness, fidelity, penetration, and sustainability. The incremental costs and benefits, in terms of quality-adjusted life years, will be examined by means of cost-utility and cost-effectiveness analyses.

DISCUSSION

MINDxYOU is designed to reduce healthcare workers' stress levels through the practice of mindfulness, acceptance, and compassion, with a special focus on how to apply these skills to healthy habits and considering the particular stressors that these professionals face on a daily basis. The present study will show how implementation studies are useful for establishing the framework in which to address barriers to and promote facilitators for acceptability, appropriateness, adoption, feasibility, fidelity, penetration, and sustainability of online interventions. The ultimate goal is to reduce the research-to-practice gap.

TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov on 29/06/2022; registration number: NCT05436717.

Trajectories of symptoms in digital interventions for depression and anxiety using Routine Outcome Monitoring data: A secondary analysis study (Preprint)

BACKGROUND

Research suggests there is heterogeneity in treatment response for internet-delivered cognitive behavioral therapy (iCBT) users, but few studies have investigated the trajectory of individual symptom change across iCBT treatment. Large patient data sets using routine outcome measures allows the investigation of treatment effects over time as well as the relationship between outcomes and platform use. Understanding trajectories of symptom change, as well as associated characteristics, may prove important for tailoring interventions or identifying patients who may not benefit from the intervention.

OBJECTIVE

We aimed to identify latent trajectories of symptom change during the iCBT treatment course for depression and anxiety and to investigate the patients' characteristics and platform use for each of these classes.

METHODS

This is a secondary analysis of data from a randomized controlled trial designed to examine the effectiveness of guided iCBT for anxiety and depression in the UK Improving Access to Psychological Therapies (IAPT) program. This study included patients from the intervention group (N=256) and followed a longitudinal retrospective design. As part of the IAPT's routine outcome monitoring system, patients were prompted to complete the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) after each supporter review during the treatment period. Latent class growth analysis was used to identify the underlying trajectories of symptom change across the treatment period for both depression and anxiety. Differences in patient characteristics were then evaluated between these trajectory classes, and the presence of a time-varying relationship between platform use and trajectory classes was investigated.

RESULTS

Five-class models were identified as optimal for both PHQ-9 and GAD-7. Around two-thirds (PHQ-9: 155/221, 70.1%; GAD-7: 156/221, 70.6%) of the sample formed various trajectories of improvement classes that differed in baseline score, the pace of symptom change, and final clinical outcome score. The remaining patients were in 2 smaller groups: one that saw minimal to no gains and another with consistently high scores across the treatment journey. Baseline severity, medication status, and program assigned were significantly associated (P<.001) with different trajectories. Although we did not find a time-varying relationship between use and trajectory classes, we found an overall effect of time on platform use, suggesting that all participants used the intervention significantly more in the first 4 weeks (P<.001).

CONCLUSIONS

Most patients benefit from treatment, and the various patterns of improvement have implications for how the iCBT intervention is delivered. Identifying predictors of nonresponse or early response might inform the level of support and monitoring required for different types of patients. Further work is necessary to explore the differences between these trajectories to understand what works best for whom and to identify early on those patients who are less likely to benefit from treatment.

Guided, internet based, cognitive behavioural therapy for post-traumatic stress disorder: pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID)

OBJECTIVE

To determine if guided internet based cognitive behavioural therapy with a trauma focus (CBT-TF) is non-inferior to individual face-to-face CBT-TF for mild to moderate post-traumatic stress disorder (PTSD) to one traumatic event.

DESIGN

Pragmatic, multicentre, randomised controlled non-inferiority trial (RAPID).

SETTING

Primary and secondary mental health settings across the UK's NHS.

PARTICIPANTS

196 adults with a primary diagnosis of mild to moderate PTSD were randomised in a 1:1 ratio to one of two interventions, with 82% retention at 16 weeks and 71% retention at 52 weeks. 19 participants and 10 therapists were purposively sampled and interviewed for evaluation of the process.

INTERVENTIONS

Up to 12 face-to-face, manual based, individual CBT-TF sessions, each lasting 60-90 minutes; or guided internet based CBT-TF with an eight step online programme, with up to three hours of contact with a therapist and four brief telephone calls or email contacts between sessions.

MAIN OUTCOME MEASURES

Primary outcome was the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at 16 weeks after randomisation (diagnosis of PTSD based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, DSM-5). Secondary outcomes included severity of PTSD symptoms at 52 weeks, and functioning, symptoms of depression and anxiety, use of alcohol, and perceived social support at 16 and 52 weeks after randomisation.

RESULTS

Non-inferiority was found at the primary endpoint of 16 weeks on the CAPS-5 (mean difference 1.01, one sided 95% confidence interval -∞ to 3.90, non-inferiority P=0.012). Improvements in CAPS-5 score of more than 60% in the two groups were maintained at 52 weeks, but the non-inferiority results were inconclusive in favour of face-to-face CBT-TF at this time point (3.20, -∞ to 6.00, P=0.15). Guided internet based CBT-TF was significantly (P<0.001) cheaper than face-to-face CBT-TF and seemed to be acceptable and well tolerated by participants. The main themes of the qualitative analysis were facilitators and barriers to engagement with guided internet based CBT-TF, treatment outcomes, and considerations for its future implementation.

CONCLUSIONS

Guided internet based CBT-TF for mild to moderate PTSD to one traumatic event was non-inferior to individual face-to-face CBT-TF and should be considered a first line treatment for people with this condition.

TRIAL REGISTRATION

ISRCTN13697710.

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

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

Predictors of Adherence in Three Low-Intensity Intervention Programs Applied by ICTs for Depression in Primary Care

Depression is one of the most common disorders in psychiatric and primary care settings, and is associated with disability, loss in quality of life, and economic costs. Internet-based psychological interventions have been shown to be effective in depression treatment but present problems with a low degree of adherence. The main aim of this study is to analyze the adherence predictors in three low-intensity interventions programs applied by Information and Communication Technologies (ICTs) for depression. A multi-center, randomized, controlled clinical trial was conducted with 164 participants with depression, who were allocated to: Healthy Lifestyle Program, Positive Affect Promotion Program or Mindfulness Program. Sociodemographic characteristics, Patient Health Questionnaire-9, Visual Analog Scale, Short Form Health Survey, Positive and Negative Affect Schedule, Five Facets Mindfulness Questionnaire, Pemberton Happiness Index and Treatment Expectancy Questionnaire were used to study adherence. Results showed that positive affect resulted in a predictor variable for Healthy Lifestyle Program and Positive Affect Promotion Program. Perceived health was also a negative adherence predictor for the Positive Affect Promotion Program. Our findings demonstrate that there are differences in clinical variables between treatment completers and non-completers and we provide adherence predictors in two intervention groups. Although new additional predictors have been examined, further research is essential in order to improve tailored interventions and increase adherence treatment.

Effectiveness of a healthy lifestyle promotion program as adjunctive teletherapy for treatment-resistant major depression during COVID 19 pandemic: A randomized clinical trial protocol

INTRODUCTION

Treatment-resistant depression (TRD) has a high prevalence and can be exacerbated by poor physical health and economic hardships, which have become common stressors during the current COVID-19 pandemic. The therapeutic approaches used to treat these patients are not always available, may be not be accepted by some patients, and often require face-to-face interactions.

OBJECTIVE

The main aim of this study will be to evaluate the effectiveness of an Internet-based adjuvant lifestyle-based intervention for patients with TRD.

METHODS

This will be a parallel, randomized, and controlled clinical trial. A total of 180 patients with TRD will be randomly allocated (1:1:1) to 1 of 3 groups: treatment prescribed by the mental health team and written suggestions for lifestyle changes (placebo control group); treatment prescribed by the mental health team, written suggestions for lifestyle changes, and an 8-week mindfulness-based cognitive therapy program (active control group); or treatment prescribed by the mental health team, written suggestions for lifestyle changes, and an 8-week lifestyle change promotion program (intervention group). We will perform this study during the COVID-19 pandemic, and will administer interventions by teletherapy, and contact participants by telephone calls, text messages, and/or teleconferences. We will collect patient data using questionnaires administered at baseline, immediately after the intervention, and after 6 and 12 months. The primary outcome will be score on the Beck Depression Inventory-II. The secondary outcomes will be score on the Clinical Global Impressions Scale (used to quantify and track patient progress and treatment response over time) and health-related quality of life measured using the European Quality of Life-5 Dimensions Questionnaire.

DISCUSSION

Patients with TRD are especially vulnerable when face-to-face psychotherapy is unavailable. The main strength of the proposed study is the novelty of the intervention to be used as an adjuvant therapy. Our results may provide guidance for treatment of patients with TRD in future situations that require lockdown measures.

CLINICALTRIALS REGISTRATION NUMBER

NCT04428099.

A guided Internet-delivered intervention for adjustment disorders: A randomized controlled trial

Evidence of self-help interventions for adjustment disorder (AjD) is limited. This study aims at testing in a randomized controlled trial (RCT) the effectiveness of a disorder-specific, Internet-delivered cognitive-behavioural therapy (ICBT) intervention for AjD. Participants were randomly allocated to either an ICBT with brief weekly telephone support (n = 34) or a waiting list group (n = 34). Beck's inventories for depression and anxiety were used as primary outcomes. The secondary outcomes were AjD symptoms, post-traumatic growth, positive and negative affect, and quality of life. In all, 76.5% of the participants completed the intervention. Compared with the control group, participants in the intervention condition showed significantly greater improvement in all outcomes (Cohen's d ranged from 0.54 to 1.21) except in anxiety symptoms measured by Beck Anxiety Inventory (d = 0.27). Only ICBT group showed a significant improvement in post-traumatic growth, positive and negative affect, and quality of life. The number of cases that achieved clinically meaningful change in all outcome measures was also higher in the ICBT group. All therapeutic gains were maintained at 3-, 6- and 12-month follow-ups. The current study provides evidence on the effectiveness of ICBT interventions to reduce the impact of AjD. Results suggest that brief self-help intervention with minimal therapist support is more effective than the mere passage of time in reducing the distress symptoms associated to the disorder and also can confer additional benefits.

Adherence to e-mental health among youth: Considerations for intervention development and research design

E-mental health programmes have great potential to provide young people with access to mental health support. However, it is commonly reported that adherence to these programmes is low. Low adherence can be problematic, particularly if young people do not receive the full benefits of a programme. In a research trial setting, non-adherence to treatment recommendations can prevent researchers from drawing strong conclusions about effectiveness. Although adherence has been recognised as an issue in need of attention, many of the reviews available are focused on adults and lack clear direction towards what strategies to employ. This paper presents a broad review of the adherence literature, focusing on factors associated with improving adherence to e-mental health among youth. Our view on the key elements to improve adherence identified from the existing literature are presented, and key recommendations for e-mental health intervention design are provided. These include: developing and communicating adherence guidelines based on individuals’ needs and symptom severity, including customisable features to provide a tailored experience and promote a sense of agency, including engagement checks and adopting a user-centred approach by utilising strategies such as co-design. This paper provides guidance to intervention designers and researchers by outlining recommendations and considerations for intervention development and research design.

Outpatient and self-referred participants: Adherence to treatment components and outcome in an internet intervention targeting anxiety disorders

OBJECTIVE

While adherence is an important factor influencing the effectiveness of internet interventions, many studies operationalize adherence only by the number of sessions and do not report adherence to specific treatment components. The goal of this study was to investigate adherence to treatment components as well as outcome in outpatients and self-referred participants who participated in an internet intervention targeting anxiety.

METHOD

Outpatients (N = 50) were compared to self-referred (N = 37) participants and a matched outpatient waitlist sample (based on nearest neighbor matching): Using t-test and χ2 tests adherence to treatment components based on the number of completed exercises was compared between participant groups. A 2 × 2 repeated measures ANOVA was used to compare pre-to post symptom change between participant groups. Primary measures included the Generalized Anxiety Disorder Scale-7 (GAD-7) and the Mini Social Phobia Inventory (Mini-SPIN). Using nonparametric bootstrap analyses number of sessions and adherence to treatment components were investigated as potential mediators of the relationship between participant group and outcome. Finally, predictors of adherence to treatment components in outpatient participants were investigated using LASSO and logistic regression.

RESULTS

Self-referred participants were more adherent than outpatient participants, however the groups did not differ significantly in outcome. Outpatient participants who adhered to relaxation showed greater improvement during the waiting period than the matched outpatient waitlist sample. The effect of participant group on outcome was mediated via adherence to exposure and number of sessions.

CONCLUSIONS

In internet interventions adherence to treatment components differs between participant groups and has a mediating effect on treatment outcome. Therefore, it should be fostered, especially when participants are not self-referred. In line with these findings more studies should investigate relevant participant characteristics in more depth.

Adherence Predictors in Internet-Delivered Self-Help Intervention for Life Stressors-Related Adjustment Disorder

Background: There is a growing body of evidence to show that low-intensity self-help internet-delivered interventions are effective in the treatment of mental disorders. Despite the promising effectiveness of internet-delivered interventions, there is still a challenge for mental health services to implement internet-delivered interventions in routine health care. The aim of this study was to analyze the predictors of adherence to a self-help internet-delivered intervention for adjustment disorder. Methods: This was a secondary report of data, including unpublished data, from a randomized controlled trial of an internet-delivered self-help intervention for adjustment disorder. The study included 1,077 participants who had completed online baseline assessments. All participants had experienced significant life stressors over the last 2 years and had high levels of adjustment disorder symptoms. We analyzed the role of sociodemographic variables, pre-treatment adjustment disorder symptoms, outcome expectations, and perceived barriers to mental health services on the use of the intervention. Results: We found that usage of internet-delivered self-help intervention and higher adherence was associated with female gender, greater age, higher pre-intervention outcome expectations, exposure to other forms of psychological therapy in addition to the internet-intervention at the time of the study, and reported perceived barriers to mental health services by the study participants. Conclusions: The findings of the study indicated the importance of non-specific therapeutic factors on adherence during internet-delivered intervention. Perceived barriers to mental health services were associated with higher adherence to self-help intervention, which indicated that communities with restricted access to mental health services could benefit from low-intensity internet-delivered interventions.