Internet- and mobile-based aftercare and relapse prevention in mental disorders: A systematic review and recommendations for future research

BACKGROUND

Mental disorders are characterized by a high likelihood of recurrence. Thus, aftercare and follow-up interventions aim to maintain treatment gains and to prevent relapse. Internet- and mobile-based interventions (IMIs) may represent promising instruments in tertiary prevention. This systematic review summarizes and evaluates the research on the efficacy of IMIs as aftercare or follow-up interventions for adults with mental health issues.

METHODS

A systematic database search (PsycInfo, MEDLINE, CENTRAL) was conducted and studies selected according to predefined eligibility criteria (RCTs, adult population, clinical symptoms/disorder, assessed with validated instruments, clinical-psychological intervention rationale, aftercare/follow-up intervention, web-/mobile-based, minimum follow-up measurement of three months, inclusion of a control group). Inspected outcomes were symptom severity, recurrence- and rehospitalization rates, functioning, quality of life and adherence to primary treatment.Systematic review registration: PROSPERO CRD42017055289.

RESULTS

Sixteen RCTs met the inclusion criteria, covering trials on depression (n = 5), eating disorders (n = 4) and transdiagnostic interventions (n = 7). The majority of the interventions were based on Cognitive Behavioral Therapy (CBT) principles and were web-based (n = 11). Methodological quality of included studies was suboptimal. Limitations included attrition bias and non-specification of routine care co-interventions. IMIs yielded small to medium post-treatment effects for symptom severity (d = -0.08 - d = -0.45) in comparison to control groups. Best evidence base was found for symptom severity of depression and anxiety. Study results regarding recurrence and rehospitalization were inconsistent.

DISCUSSION

There is some evidence, that IMIs are feasible instruments for maintaining treatment gains for some mental disorders. However, further high quality, large-scale trials are needed to expand research fields, improve adherence to and uptake of IMIs and facilitate implementation of effective interventions into routine care.

Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled Trial

BACKGROUND

Mental disorders have become a major health issue, and a substantial number of afflicted individuals do not get appropriate treatment. Web-based interventions are promising supplementary tools for improving health care for patients with mental disorders, as they can be delivered at low costs and used independently of time and location. Although psychodynamic treatments are used frequently in the face-to-face setting, there has been a paucity of studies on psychodynamic Web-based self-help interventions.

OBJECTIVE

The objective of this study was to determine the feasibility and preliminary efficacy of a transdiagnostic affect-focused psychodynamic Web-based self-help intervention designed to increase emotional competence of patients with mental disorders.

METHODS

A total of 82 psychotherapy inpatients with mixed diagnoses were randomized into two groups. Following discharge, the intervention group (IG) got access to a guided version of the intervention for 10 weeks. After a waiting period of 10 weeks, the wait-list control group (WLCG) got access to an unguided version of the intervention. We reported the assessments at the beginning (T0) and at the end of the intervention, resp. the waiting period (T1). The primary outcome was satisfaction with the treatment at T1. Secondary outcome measures included emotional competence, depression, anxiety, and quality of life. Statistical analyses were performed with descriptive statistics (primary outcome) and analysis of covariance; a repeated measurement analysis of variance was used for the secondary outcomes. Effect sizes were calculated using Cohen d and data were analyzed as per protocol, as well as intention-to-treat (ITT).

RESULTS

Patients were chronically ill, diagnosed with multiple diagnoses, most frequently with depression (84%, 58/69), anxiety (68%, 47/69), personality disorder (38%, 26/69), and depersonalization-derealization disorder (22%, 15/69). A majority of the patients (86%, 36/42) logged into the program, of which 86% (31/36) completed the first unit. Satisfaction with the units mastered was rated as good (52%, 16/31) and very good (26%, 9/31). However, there was a steady decline of participation over the course of the program; only 36% of the participants (13/36) participated throughout the trial completing at least 50% of the sessions. According to the ITT analysis, participants improved statistically significantly and with moderate effect sizes (Cohen d) compared with the WLCG regarding depression (d=0.60), quality of life (d=0.53), and emotional competence (d=0.49). Effects were considerably stronger for the completers with respect to depression (d=1.33), quality of life (d=0.83), emotional competence (d=0.68), and general anxiety (d=0.62).

CONCLUSIONS

Although overall program satisfaction and benefit of the program were favorable with respect to the indicators of emotional disorders, the rate of completion was low. Our findings point to the need to target the intervention more specifically to the needs and capabilities of participants and to the context of the intervention.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02671929; https://clinicaltrials.gov/ct2/show/NCT02671929 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb).

Using a transdiagnostic, psychodynamic online self-help intervention to maintain inpatient psychosomatic treatment effects: Study protocol of a feasibility study

BACKGROUND

Online self-help interventions have proven to be effective in treating various specific mental disorders, mainly depression and anxiety. Knowledge regarding their acceptance, efficacy, and usefulness in addition to inpatient or outpatient psychotherapy is limited. Therefore, we plan to evaluate an affect-focused, transdiagnostic, psychodynamic online self-help intervention following inpatient psychotherapy for mixed diagnoses in a feasibility study to determine acceptance, satisfaction, and preliminary estimates of efficacy.

METHODS

The intervention is based on the book "Living Like You Mean It" by Ronald J. Frederick (2009) and the Swedish adaption by Johansson and colleagues (2013). The book was translated into German and thoroughly revised using parts of the Swedish adaption and additional tasks from their intervention. In a pilot phase, corrections concerning comprehensibility of the content and exercises were made based on patient's feedback. In the second step, we developed a website presenting the German adaption in eight units. In the third step, at least N = 66 patients from the Department of Psychosomatic Medicine and Psychotherapy will be recruited for a feasibility study. Patients are randomized into two groups. The intervention group (IG) will receive ten weeks of access to the online self-help intervention together with weekly therapeutic feedback on their progress. The wait-list control group (WLC) will receive access to the intervention for ten weeks as well, but without therapeutic feedback and with a ten-week delay. We will conduct assessments at the beginning of the intervention of the IG (T0), the end of the intervention of the IG (T1), two months later (only IG, T2), and at the end of the intervention of the WLC (T3). The primary outcome is satisfaction with the treatment as measured by the ZUF-8 at T1 and T3 respectively. Secondary outcome measures include emotional competence, depression, anxiety, and quality of life.

CONCLUSION

We expect insight into the usefulness and acceptance of an online self-help intervention used to maintain inpatient treatment effects. Furthermore, we await both groups to benefit from the participation in the intervention. Pre- post and between subject differences will be used as estimate effect sizes to calculate the necessary sample size for a larger efficacy trial.

Client emotional productivity-optimal client in-session emotional processing in experiential therapy

OBJECTIVE

The goal of this investigation was to examine the predictive validity of Client Emotional Productivity (CEP), an operationalization of optimal client in-session emotional processing, possessing seven features: Attending, symbolization, congruence, acceptance, regulation, agency and differentiation.

METHOD

CEP was related to improvement in depressive and general symptoms, in 74 clients (66% female, 34% male) who received experiential therapy of depression and this was compared to the relationship between client high expressed emotional (CHEEA) arousal and the working alliance (WAI) and outcome.

RESULTS

Hierarchical regression analyses revealed that working phase CEP predicted significant reduction of depressive and general symptoms over and above that predicted by beginning phase CEP, the working alliance and working phase CHEEA. Working phase CEP emerged as the sole, independent predictor of outcome for both depressive and general symptoms.

CONCLUSION

Productive emotional processing, thus, mediates the relationship between the alliance and outcome and seems to go beyond mere activation and expression of emotional experience. It rather seems to involve an increase in the ability to process activated primary emotion in a productive manner specified by CEP.

A longitudinal study of emotional experience, expressivity, and psychopathology in psychotherapy inpatients and psychologically healthy persons

The authors investigated changes of emotional experience and expressivity in 34 inpatients undergoing psychodynamic therapy and in 29 healthy persons who were assessed at parallel time intervals. Participants completed 2 measures of psychopathology (Symptom Checklist-90 Revised and Inventory of Interpersonal Problems-64) and took part in relationship episode interviews. The emotional experiences they reported and their nonverbal emotional expressivity during the interviews were assessed by independent raters. Regardless of when they were assessed, the patients reported a greater number of emotions and a greater variety of emotions. Psychopathology in the patient group decreased in the course of treatment, but there were no systematic changes in the emotional domain. The findings challenge the common notion of psychopathology being associated with impaired awareness and expression of emotions.