Treating Youth Depression and Anxiety: A Randomised Controlled Trial Examining the Efficacy of Computerised versus Face‐to‐face Cognitive Behaviour Therapy

Internet-delivered transdiagnostic psychological treatments for individuals with depression, anxiety or both: a systematic review with meta-analysis of randomised controlled trials

OBJECTIVE

Depression and anxiety are major public health problems. This study evaluated the effects of internet-delivered transdiagnostic psychological treatments for individuals with depression, anxiety, or both.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Medline (Ovid), Cochrane Library (Wiley), the Web of Science Core Collection (Clarivate), and PsycInfo (EBSCO) were searched on 24 May 2021, with an update on 6 February 2023.

ELIGIBILITY CRITERIA

Randomised controlled trials of internet-delivered transdiagnostic psychological treatments, open to both participants with primary depression and participants with primary anxiety. This review concerned all treatment frameworks, both guided and unguided formats and all age groups.

DATA EXTRACTION AND SYNTHESIS

In random-effects meta-analysis, we estimated pooled effects on depression symptoms and anxiety in terms of Hedges' g with 95% CIs. Absolute and relative heterogeneity was quantified as the τ2 and I 2.

RESULTS

We included 57 trials with 21 795 participants. Nine trials (16%) recruited exclusively from routine care, and three (5%) delivered treatment via video. For adults, large within-group reductions were seen in depression (g=0.90; 95% CI 0.81 to 0.99) and anxiety (g=0.87; 95% CI 0.78 to 0.96). Compared with rudimentary passive controls, the added effects were moderate (depression: g=0.52; 95% CI 0.42 to 0.63; anxiety: g=0.45; 95% CI 0.34 to 0.56) and larger in trials that required all participants to meet full diagnostic criteria for depression or an anxiety disorder. Compared with attention/engagement controls, the added effects were small (depression: g=0.30; 95% CI 0.07 to 0.53; anxiety: g=0.21; 95% CI 0.01 to 0.42). Heterogeneity was substantial, and the certainty of the evidence was very low. Two trials concerned adolescents and reported mixed results. One trial concerned older adults and reported promising results.

CONCLUSION

Internet-delivered transdiagnostic treatments for depression and anxiety show small-to-moderate added effects, varying by control condition. Research is needed regarding routine care, the video format, children and adolescents and older adults.

PROSPERO REGISTRATION NUMBER

CRD42021243172.

A Novel Blended Transdiagnostic Intervention (eOrygen) for Youth Psychosis and Borderline Personality Disorder: Uncontrolled Single-Group Pilot Study

BACKGROUND

Integrating innovative digital mental health interventions within specialist services is a promising strategy to address the shortcomings of both face-to-face and web-based mental health services. However, despite young people's preferences and calls for integration of these services, current mental health services rarely offer blended models of care.

OBJECTIVE

This pilot study tested an integrated digital and face-to-face transdiagnostic intervention (eOrygen) as a blended model of care for youth psychosis and borderline personality disorder. The primary aim was to evaluate the feasibility, acceptability, and safety of eOrygen. The secondary aim was to assess pre-post changes in key clinical and psychosocial outcomes. An exploratory aim was to explore the barriers and facilitators identified by young people and clinicians in implementing a blended model of care into practice.

METHODS

A total of 33 young people (aged 15-25 years) and 18 clinicians were recruited over 4 months from two youth mental health services in Melbourne, Victoria, Australia: (1) the Early Psychosis Prevention and Intervention Centre, an early intervention service for first-episode psychosis; and (2) the Helping Young People Early Clinic, an early intervention service for borderline personality disorder. The feasibility, acceptability, and safety of eOrygen were evaluated via an uncontrolled single-group study. Repeated measures 2-tailed t tests assessed changes in clinical and psychosocial outcomes between before and after the intervention (3 months). Eight semistructured qualitative interviews were conducted with the young people, and 3 focus groups, attended by 15 (83%) of the 18 clinicians, were conducted after the intervention.

RESULTS

eOrygen was found to be feasible, acceptable, and safe. Feasibility was established owing to a low refusal rate of 25% (15/59) and by exceeding our goal of young people recruited to the study per clinician. Acceptability was established because 93% (22/24) of the young people reported that they would recommend eOrygen to others, and safety was established because no adverse events or unlawful entries were recorded and there were no worsening of clinical and social outcome measures. Interviews with the young people identified facilitators to engagement such as peer support and personalized therapy content, as well as barriers such as low motivation, social anxiety, and privacy concerns. The clinician focus groups identified evidence-based content as an implementation facilitator, whereas a lack of familiarity with the platform was identified as a barrier owing to clinicians' competing priorities, such as concerns related to risk and handling acute presentations, as well as the challenge of being understaffed.

CONCLUSIONS

eOrygen as a blended transdiagnostic intervention has the potential to increase therapeutic continuity, engagement, alliance, and intensity. Future research will need to establish the effectiveness of blended models of care for young people with complex mental health conditions and determine how to optimize the implementation of such models into specialized services.

[Efficacy of internet-based interventions for depression available in Germany-A systematic review and meta-analysis]

BACKGROUND

Internet-based interventions (IBIs) for the treatment of depression have been found to have positive effects in international meta-analyses; however, it is unclear whether these effects also extend to IBIs specifically available in Germany. The aim of this meta-analysis was to estimate the immediate effects and the long-term effects of IBIs available in Germany free of charge or available on prescription and covered by the public health insurances as so-called digital health applications (DiGAs) and to compare the efficacy of DiGAs and freely available IBIs.

METHOD

A systematic literature search and random-effects meta-analysis were performed (preregistration: INPLASY202250070). Randomized controlled trials (RCTs) of IBIs freely available in Germany or as DiGA in adults with elevated depressive symptoms were compared with active and inactive controls available at the time of the survey in May 2022.

RESULTS

A total of six interventions were identified: COGITO, deprexis, iFightDepression, moodgym, Novego, and Selfapy. The pooled effect size of a total of 28 studies with 13,413 participants corresponded to an effect of Cohen's d = 0.42, (95% confidence interval, CI: 0.31-0.54, I2 = 81%). The analysis of long-term effects showed a smaller effect size of d = 0.29, (95% CI: 0.21-0.37, I2 = 22%, N = 10). Subgroup analyses indicated a possible superiority of the three interventions listed in the DiGA directory (d = 0.56, 95% CI: 0.38-0.74, I2 = 83%, N = 15) compared to the three freely available IBIs (d = 0.24, 95% CI: 0.14-0.33, I2 = 44%, N = 13, p = 0.002).

CONCLUSION

The IBIs for depressive disorders available in Germany are effective and can therefore be used in the treatment of people with a depressive disorder; however, it is possible that not all interventions are equally effective.

Study protocol for a randomized controlled trial testing the efficacy of Emotion Detectives In-Out: a blended version of the unified protocol for transdiagnostic treatment of emotional disorders in Portuguese children

BACKGROUND

Childhood emotional disorders (EDs; i.e., anxiety and depressive disorders) are currently a public health concern. Their high prevalence, long-term effects, and profound influence on the lives of children and families highlight the need to identify and treat these disorders as early and effectively as possible. This clinical trial will examine the efficacy of a blended version (i.e., combining face-to-face and online sessions into one treatment protocol) of the Unified Protocol for Children (the "Emotion Detectives In-Out" program). This program is a manualized cognitive-behavioral therapy for the transdiagnostic treatment of EDs in children aged 7 to 12 years that aims to reduce the intensity and frequency of strong and aversive emotional experiences by helping children learn how to confront those emotions and respond to them in more adaptive ways.

METHODS

This study is designed as a multicenter equivalence randomized controlled parallel-group two-arm trial comparing the Emotion Detectives In-Out program with an evidenced-based group intervention for children with anxiety disorders (the Coping Cat program). Participants will be children aged between 7 and 12 years with an anxiety disorder or with clinically significant anxiety symptoms as well as one of their parents or a legal representative. A minimum sample size of 138 children (69 per group) is needed to test whether the efficacy of the proposed intervention is equivalent to that of the well-established Coping Cat intervention.

DISCUSSION

We expect Emotion Detectives In-Out to be a feasible and efficacious alternative intervention for treating children's EDs by allowing for a greater increase in children's access to care. A blended format is expected to overcome common barriers to treatment (e.g., parents´ lack of time to attend regular sessions) and make the intervention more accessible to families.

TRIAL REGISTRATION

The clinical trial is registered at ClinicalTrials.gov (Identifier: NCT05747131, date assigned February 28, 2023).

Parents' acceptability of blended psychological interventions for children with emotional disorders

Objectives

This study aims to (1) describe parents' knowledge and use of online resources to address children's mental health issues and the family's general internet and technology usage patterns; (2) examine parents' acceptance of blended interventions for children with emotional disorders (ED); and (3) analyse the predictors of parents' intention to use a blended intervention if their children experienced an ED.

Method

The sample included 164 Portuguese parents (95.7 % mothers) of children between the ages of 6 and 13 years who completed an online survey. The study was disseminated through social networks, personal contacts of the researchers, and among parents participating in a randomized controlled trial investigating the efficacy of a psychological intervention for children with ED.

Results

Only 4.3 % of parents knew about online psychological interventions for children, and only 1.2 % had used them before. Most parents (73.2 %) reported that they would choose face-to-face individual therapy as their first option if their child had any ED, followed by blended therapy (14.8 %). Regression analyses showed that higher levels of parents' intention to use a blended intervention were predicted by their perceptions of the utility or efficacy of this type of delivery format.

Discussion/conclusion

These results suggest that although most parents show unfamiliarity with blended psychological interventions for children, they consider it a treatment modality to which they would resort if their children had emotional difficulties. Their intention to use such an intervention seems to be more likely if they perceive it as useful and effective.

A systematic review and meta-analysis of Internet-based self-help interventions for mental health among adolescents and college students

Purpose

This meta-analysis aims to evaluate the impact of Internet-based self-help interventions on the mental health of adolescents and college students.

Methods

We conducted a systematic review of randomized controlled trials (RCTs) that investigated Internet-based self-help interventions aiming to mitigate mental health symptoms such as anxiety and depression, as well as managing high levels of stress, among adolescents and college students. Our search spanned databases including Web of Science, PubMed, Cochrane Library, and Embase, up until November 1st, 2022. It is essential to emphasize that our focus was the evaluation of symptoms (continuous outcomes), rather than the diagnosis of specific mental disorders. The meta-analysis was performed using the R version 4.3.1. The effect size measure was the standardized mean difference (SMD), and random-effects models were used to pool data from eligible RCTs. Subgroup analyses were carried out to examine variations in intervention effects based on factors such as sample type, intervention modality, guidance type, and intervention duration.

Results

The meta-analysis was based on 25 comparisons involving a total of 4480 participants. In comparison to the control group (n = 2125), participants receiving interventions (n = 2355) reported significant reductions in symptoms of anxiety, depression, and stress, along with a significant improvement in quality of life. Specifically, for depression, we observed moderate intervention effects (SMD = -0.42, 95 % CI: -0.56, -0.27), and a similar pattern was seen for quality of life (SMD = 0.36, 95%CI: 0.22, 0.49). Small intervention effects were found for anxiety (SMD = -0.35, 95 % CI [-0.48, -0.22]) and stress (SMD = -0.35, 95 % CI [-0.51, -0.20]). Given significant heterogeneity, subgroup analyses were conducted for anxiety and depression, considering factors such as sample type, intervention method, and intervention duration. Notably, college students experienced more significant benefits in both anxiety and depression alleviation compared to adolescents. Longer interventions (>8 weeks) were particularly effective in reducing anxiety and depression. Additionally, third-wave cognitive-behavioral therapy (CBT) showed pronounced intervention effects in both outcome measures, while the presence of guidance did not notably influence results.

Conclusion

This meta-analysis underscores the positive impact of Internet-based self-help programs in alleviating the symptoms of psychological disorders among adolescents and college students. However, it is crucial to acknowledge that the available evidence exhibits inconsistencies and limitations. Therefore, further research utilizing rigorous methodologies is necessary to verify and broaden the findings of this meta-analysis.

Online cognitive behavioral therapy (eCBT) for the management of depression symptoms in unipolar and bipolar spectrum disorders, a systematic review and network meta-analysis

BACKGROUND

Face-to-face cognitive behavioral therapy (CBT) is effective in the management of depression symptoms in unipolar and bipolar spectrum disorders. Though, compared to electronic adaptations of CBT (eCBT), it carries several accessibility limitations. Furthermore, unlike eCBT for depression symptoms (eCBTg), eCBT specific for bipolar depression (eCBT-Bipol) remains largely understudied. Thus, supplementing this gap, this systematic review and network meta-analysis (NMA) synthesized the available literature on eCBT for the treatment of unipolar and bipolar depression symptoms.

METHOD

MEDLINE, CINAHL, PsycINFO, EMBASE, and Cochrane were searched for relevant randomized controlled trials (RCTs) on eCBTg and eCBT-Bipol The review followed PRISMA guidelines and used the Cochrane risk of bias tool and GRADE criteria for quality assessment. Effect sizes were summarized using standardized mean differences (SMDs) and risk ratios (RRs).

RESULTS

eCBT-Bipol was comparable to eCBTg (SMD: 0.05, 95 % CI: -0.18; 0.28) and other psychotherapeutic interventions (SMD: 0.14, 95 % CI: -0.07; 0.35) for the management of mild to moderate depression symptoms. eCBT-Bipol was significantly more effective than attention controls (SMD: 0.35, 95 % CI: 0.11; 0.59), treatment as usual (SMD: 0.55, 95 % CI: 0.21; 0.90) and no intervention controls (SMD: 0.66, 95 % CI: 0.40; 0.93) in mitigating symptoms.

LIMITATIONS

The scarcity of eCBT-Bipol studies impacted the quality of the evidence in terms of risk of bias and imprecision.

CONCLUSIONS

The findings of this systematic review suggest that eCBT-Bipol has comparable effectiveness to eCBTg in managing depressive symptoms of unipolar and bipolar spectrum disorder. Though, they also highlighted the need for more studies on eCBT-Bipol.

Using Digital Measurement-Based Care for the Treatment of Anxiety and Depression in Children and Adolescents: Observational Retrospective Analysis of Bend Health Data

BACKGROUND

A growing body of evidence supports the efficacy of measurement-based care (MBC) for children and adolescents experiencing mental health concerns, particularly anxiety and depression. In recent years, MBC has increasingly transitioned to web-based spaces in the form of digital mental health interventions (DMHIs), which render high-quality mental health care more accessible nationwide. Although extant research is promising, the emergence of MBC DMHIs means that much is unknown regarding their effectiveness as a treatment for anxiety and depression, particularly among children and adolescents.

OBJECTIVE

This study uses preliminary data from children and adolescents participating in an MBC DMHI administered by Bend Health Inc, a mental health care provider that uses a collaborative care model to assess changes in anxiety and depressive symptoms during participation in the MBC DMHI.

METHODS

Caregivers of children and adolescents participating in Bend Health Inc for anxiety or depressive symptoms reported measures of their children's symptoms every 30 days throughout the duration of participation in Bend Health Inc. Data from 114 children (age 6-12 years) and adolescents (age 13-17 years) were used for the analyses (anxiety symptom group: n=98, depressive symptom group: n=61).

RESULTS

Among children and adolescents participating in care with Bend Health Inc, 73% (72/98) exhibited improvements in anxiety symptoms and 73% (44/61) exhibited improvement in depressive symptoms, as indicated by either a decrease in symptom severity or screening out of completing the complete assessment. Among those with complete assessment data, group-level anxiety symptom T-scores exhibited a moderate decrease of 4.69 points (P=.002) from the first to the last assessment. However, members' depressive symptom T-scores remained largely stable throughout their involvement.

CONCLUSIONS

As increasing numbers of young people and families seek DMHIs over traditional mental health treatments due to their accessibility and affordability, this study offers promising early evidence that youth anxiety symptoms decrease during involvement in an MBC DMHI such as Bend Health Inc. However, further analyses with enhanced longitudinal symptom measures are necessary to determine whether depressive symptoms show similar improvements among those involved in Bend Health Inc.

Web-Based Interventions to Help Australian Adults Address Depression, Anxiety, Suicidal Ideation, and General Mental Well-being: Scoping Review

BACKGROUND

A large number of Australians experience mental health challenges at some point in their lives. However, in many parts of Australia, the wait times to see general practitioners and mental health professionals can be lengthy. With increasing internet use across Australia, web-based interventions may help increase access to timely mental health care. As a result, this is an area of increasing research interest, and the number of publicly available web-based interventions is growing. However, it can be confusing for clinicians and consumers to know the resources that are evidence-based and best meet their needs.

OBJECTIVE

This study aims to scope out the range of web-based mental health interventions that address depression, anxiety, suicidal ideation, or general mental well-being and are freely available to Australian adults, along with their impact, acceptability, therapeutic approach, and key features.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews (PRISMA-ScR [PRISMA extension for Scoping Reviews]) guided the review process. Keywords for the search were depression, anxiety, suicide, and well-being. The search was conducted using Google as well as the key intervention databases Beacon, Head to Health, and e-Mental Health in Practice. Interventions were deemed eligible if they targeted depression, anxiety, suicidal ideation, or general mental well-being (eg, resilience) in adults; and were web-based, written in English, interactive, free, and publicly available. They also had to be guided by an evidence-based therapeutic approach.

RESULTS

Overall, 52 eligible programs were identified, of which 9 (17%) addressed depression, 15 (29%) addressed anxiety, 13 (25%) addressed general mental well-being, and 13 (25%) addressed multiple issues. Only 4% (2/52) addressed distress in the form of suicidal ideation. The most common therapeutic approach was cognitive behavioral therapy. Half of the programs guided users through exercises in a set sequence, and most programs enabled users to log in and complete the activities on their own without professional support. Just over half of the programs had been evaluated for their effectiveness in reducing symptoms, and 11% (6/52) were being evaluated at the time of writing. Program evaluation scores ranged from 44% to 100%, with a total average score of 85%.

CONCLUSIONS

There are numerous web-based programs for depression, anxiety, suicidal ideation, and general well-being, which are freely and publicly available in Australia. However, identified gaps include a lack of available web-based interventions for culturally and linguistically diverse populations and programs that use newer therapeutic approaches such as acceptance and commitment therapy and dialectical behavior therapy. Despite most programs included in this review being of good quality, clinicians and consumers should pay careful attention when selecting which program to recommend and use, as variations in the levels of acceptability and impact of publicly available programs do exist.

Virtual versus Face-to-Face Cognitive Behavioral Treatment of Depression: Meta-Analytic Test of a Noninferiority Hypothesis and Men's Mental Health Inequities

Global rates of depression have increased significantly since the beginning of the COVID-19 pandemic. It is unclear how the recent shift of many mental health services to virtual platforms has impacted service users, especially for the male population which are significantly more likely to complete suicide than women. This paper presents the findings of a rapid meta-analytic research synthesis of 17 randomized controlled trials on the relative efficacy of virtual versus traditional face-to-face cognitive behavioral therapy (CBT) in mitigating symptoms of depression. Participants' aggregated depression scores were compared upon completion of the therapy (posttest) and longest follow-up measurement. The results supported the noninferiority hypothesis indicating that the two modes of CBT delivery are equally efficacious, but the results proved to be significantly heterogeneous indicating the presence of moderating effects. Indirect suggestive evidence was found to support moderation by gender; that is, depressed males may benefit more from virtual CBT. Perhaps, this field's most telling descriptive finding was that boys/men have been grossly underrepresented in its trials. Future trials ought to oversample those who have been at this field's margins to advance the next generation of knowledge, allowing us to best serve people of all genders, those who live in poverty, Indigenous, Black, and other Peoples of Colour, as well as any others at risk of being marginalized or oppressed in contemporary mental health care systems.

Examining the Effectiveness of Gamification in Mental Health Apps for Depression: Systematic Review and Meta-analysis

BACKGROUND

Previous research showed that computerized cognitive behavioral therapy can effectively reduce depressive symptoms. Some mental health apps incorporate gamification into their app design, yet it is unclear whether features differ in their effectiveness to reduce depressive symptoms over and above mental health apps without gamification.

OBJECTIVE

The aim of this study was to determine whether mental health apps with gamification elements differ in their effectiveness to reduce depressive symptoms when compared to those that lack these elements.

METHODS

A meta-analysis of studies that examined the effect of app-based therapy, including cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness, on depressive symptoms was performed. A total of 5597 articles were identified via five databases. After screening, 38 studies (n=8110 participants) remained for data extraction. From these studies, 50 total comparisons between postintervention mental health app intervention groups and control groups were included in the meta-analysis.

RESULTS

A random effects model was performed to examine the effect of mental health apps on depressive symptoms compared to controls. The number of gamification elements within the apps was included as a moderator. Results indicated a small to moderate effect size across all mental health apps in which the mental health app intervention effectively reduced depressive symptoms compared to controls (Hedges g=-0.27, 95% CI -0.36 to -0.17; P<.001). The gamification moderator was not a significant predictor of depressive symptoms (β=-0.03, SE=0.03; P=.38), demonstrating no significant difference in effectiveness between mental health apps with and without gamification features. A separate meta-regression also did not show an effect of gamification elements on intervention adherence (β=-1.93, SE=2.28; P=.40).

CONCLUSIONS

The results show that both mental health apps with and without gamification elements were effective in reducing depressive symptoms. There was no significant difference in the effectiveness of mental health apps with gamification elements on depressive symptoms or adherence. This research has important clinical implications for understanding how gamification elements influence the effectiveness of mental health apps on depressive symptoms.

Randomized controlled trial of online interventions for co-occurring depression and hazardous alcohol consumption: Primary outcome results

BACKGROUND AND AIMS

The current trial tested the benefits of offering a brief online intervention for hazardous alcohol consumption along with one for depression among people experiencing both conditions.

METHODS

Online advertisements were used to recruit people with persistent low mood. Those who also had current hazardous alcohol consumption were identified and invited to take part in the trial (those not eligible were offered access to the online depression intervention). Participants were randomized to an established intervention for depression (MoodGYM; M-only) or to receive MoodGYM plus a brief personalized feedback intervention for hazardous drinking (Check Your Drinking; M + CYD). Participants were followed-up at three and six months.

RESULTS

While levels of depression symptoms (p < .001) and hazardous alcohol consumption (p < .001) reduced in both the M-only and the M + CYD groups, there was no difference between groups on drinking (p = .374) or depression outcomes (p = .752). Further, participants who were provided both interventions logged into the intervention website less often (M = 4.1, SD = 3.9) compared to participants only offered the depression intervention (M = 4.9, SD = 5.2), t (986) = 2.47, p = .014. However, there was no significant difference (p > .05) in the number of MoodGYM modules completed between the two groups.

DISCUSSION AND CONCLUSION

The current trial found no benefit to providing a brief online intervention for hazardous alcohol consumption alongside one for depression among people experiencing these co-occurring disorders. Further, the finding that adding an online intervention for drinking to one for depression led to a small reduction in the number of times the interventions were accessed implies the need for caution when deciding how best to provide online help to those with co-occurring depression and hazardous alcohol consumption.Trial Registration: ClinicalTrials.govNCT03421080.

Pragmatic Quasi-Experimental Controlled Trial Evaluating the Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders

Depression is a major problem in youth mental health. Current treatment is on average effective, but adolescents are hesitant to seek help. Blended treatment could lower the barriers to seeking treatment. Evidence on effectiveness is, however, scarce. The present pragmatic quasi-experimental controlled trial aimed to compare the outcomes of blended cognitive behavioral therapy (CBT) to face-to-face CBT and treatment as usual. A total of 129 adolescents with clinical depression (82.2% female), aged 13–22 (M = 16.60, SD = 2.03) received blended CBT, face-to-face CBT or treatment as usual. Clinical diagnosis, depressive symptoms, and secondary outcomes were assessed at baseline, post-intervention, and six-months follow-up. Participants receiving blended CBT were, compared to participants receiving face-to-face CBT and treatment as usual, evenly likely to be in remission from their depressive disorder at post-intervention and at six-month follow-up. Depressive symptoms decreased significantly over time in all three conditions, and changes were not significantly different between conditions. Other secondary outcomes (suicide risk, internalizing and externalizing symptoms, severity of depression, and global functioning) did not differ between treatment conditions at post-intervention and six-month follow-up. Since there was no evidence for favorable outcomes for face-to-face therapies above blended CBT, blended CBT may also be an effective treatment format in clinical practice.

Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis

Background

There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development.

Objective

This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom.

Methods

Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls.

Results

A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found.

Conclusions

Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects.

Trial Registration

International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184

Preventive digital mental health interventions for children and young people: a review of the design and reporting of research

Digital health interventions (DHIs) have frequently been highlighted as one way to respond to increasing levels of mental health problems in children and young people. Whilst many are developed to address existing mental health problems, there is also potential for DHIs to address prevention and early intervention. However, there are currently limitations in the design and reporting of the development, evaluation and implementation of preventive DHIs that can limit their adoption into real-world practice. This scoping review aimed to examine existing evidence-based DHI interventions and review how well the research literature described factors that researchers need to include in their study designs and reports to support real-world implementation. A search was conducted for relevant publications published from 2013 onwards. Twenty-one different interventions were identified from 30 publications, which took a universal (n = 12), selective (n = 3) and indicative (n = 15) approach to preventing poor mental health. Most interventions targeted adolescents, with only two studies including children aged ≤10 years. There was limited reporting of user co-design involvement in intervention development. Barriers and facilitators to implementation varied across the delivery settings, and only a minority reported financial costs involved in delivering the intervention. This review found that while there are continued attempts to design and evaluate DHIs for children and young people, there are several points of concern. More research is needed with younger children and those from poorer and underserved backgrounds. Co-design processes with children and young people should be recognised and reported as a necessary component within DHI research as they are an important factor in the design and development of interventions, and underpin successful adoption and implementation. Reporting the type and level of human support provided as part of the intervention is also important in enabling the sustained use and implementation of DHIs.

Blended Treatment for Depressive Disorders in Youth: a Narrative Review

Depressive disorders are the most prevalent mental health disorder in adolescents with detrimental consequences; effective and available treatment is crucial. Face-to-face and computerized treatments both have advantages but also downsides. Merging these two into one so-called blended treatment seems to be an optimal combination of elements. This current review addresses blended treatment for youth depression and aims to summarize existing knowledge on effectiveness as well as patients’ and therapists’ perspectives. Results showed promising significant decreases in symptoms, but no evidence for differences between blended and face-to-face treatment was found. Patients’ perspectives were mixed; they reported strong preferences for face-to-face treatment, but participants actually receiving blended treatment were mainly positive. Therapists’ attitudes were neutral, but they expressed their worries about the unknown risks on adverse events. Future research is needed and should, beside effectiveness and cost-effectiveness, pay close attention to the risks that are mentioned by therapists.

Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis

BACKGROUND

Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited.

OBJECTIVE

The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects.

METHODS

We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome.

RESULTS

The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI -0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=-0.70, 95% CI -1.51 to 0.11, P=.09), but heterogeneity was very high (I2=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies.

CONCLUSIONS

cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population.

TRIAL REGISTRATION

PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9.

A comparison of electronically-delivered and face to face cognitive behavioural therapies in depressive disorders: A systematic review and meta-analysis

BACKGROUND

Cognitive behavioural therapy (CBT) is a widely used treatment for depression. However, limited resource availability poses several barriers to patients seeking access to care, including lengthy wait times and geographical limitations. This has prompted health care services to introduce electronically delivered CBT (eCBT) to facilitate access. Although previous reviews have compared the effects of eCBT to face-to-face CBT, there is an overall lack of adequately powered and up-to-date evidence in the literature to provide a reliable comparison between the two modes of administration. The purpose of this study is to evaluate the effects of eCBT compared to face-to-face CBT through a systematic review of the literature.

METHODS

To be eligible for this review, studies needed to be randomized controlled trials evaluating the clinical effectiveness of any form of eCBT compared to face-to-face CBT. These encompassed studies evaluating a wide range of outcomes including severity of symptoms, adverse outcomes, clinically relevant outcomes, global functionality, participant satisfaction, quality of life, and affordability. There were no restrictions on participant age or sex.We searched MEDLINE, EMBASE, Psych Info, Cochrane CENTRAL and CINAHL databases from inception to February 20th, 2020 using a comprehensive search strategy. All stages of literature screening and data extraction were completed independently in duplicate. Data extraction and risk of bias analyses, including GRADE ratings, were conducted on studies meeting inclusion criteria. Qualitative measures are reported in a narrative summary. We pooled quantitative data in meta-analyses to provide an estimated summary effect. This review adheres to PRISMA reporting guidelines.

FINDINGS

In total, we included 17 studies in our analyses. Our results demonstrated that eCBT was more effective than face-to-face CBT at reducing depression symptom severity (Standardized mean difference [SMD]: -1.73; 95% confidence interval [CI]: -2.72, -0.74; GRADE: moderate quality of evidence). There were no significant differences between the two interventions on participant satisfaction (SMD 0.13 95%; CI -0.32, 0.59; GRADE: low quality of evidence). One RCT reported eCBT to be less costly than face-to-face CBT (GRADE: low quality of evidence). Results did not differ when stratified by subgroups such as participant age and study location.

INTERPRETATION

Although we found eCBT to have moderate evidence of effectiveness in reducing symptoms of depression, high heterogeneity among studies precludes definitive conclusions for all outcomes. With the current reliance and accessibility of technology to increasing number of people worldwide, serious consideration in utilizing technology should be given to maximize accessibility for depression treatments. Our results found eCBT is at least as effective as face to face CBT, thus eCBT should be offered if preferred by patients and therapists.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Engaging Children and Young People in Digital Mental Health Interventions: Systematic Review of Modes of Delivery, Facilitators, and Barriers

BACKGROUND

There is a high prevalence of children and young people (CYP) experiencing mental health (MH) problems. Owing to accessibility, affordability, and scalability, an increasing number of digital health interventions (DHIs) have been developed and incorporated into MH treatment. Studies have shown the potential of DHIs to improve MH outcomes. However, the modes of delivery used to engage CYP in digital MH interventions may differ, with implications for the extent to which findings pertain to the level of engagement with the DHI. Knowledge of the various modalities could aid in the development of interventions that are acceptable and feasible.

OBJECTIVE

This review aimed to (1) identify modes of delivery used in CYP digital MH interventions, (2) explore influencing factors to usage and implementation, and (3) investigate ways in which the interventions have been evaluated and whether CYP engage in DHIs.

METHODS

A literature search was performed in the Cochrane Library, Excerpta Medica dataBASE (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), and PsycINFO databases using 3 key concepts "child and adolescent mental health," "digital intervention," and "engagement." Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least two reviewers. The selected articles were assessed for quality using the mixed methods appraisal tool, and data were extracted to address the review aims. Data aggregation and synthesis were conducted and presented as descriptive numerical summaries and a narrative synthesis, respectively.

RESULTS

This study identified 6 modes of delivery from 83 articles and 71 interventions for engaging CYP: (1) websites, (2) games and computer-assisted programs, (3) apps, (4) robots and digital devices, (5) virtual reality, and (6) mobile text messaging. Overall, 2 themes emerged highlighting intervention-specific and person-specific barriers and facilitators to CYP's engagement. These themes encompassed factors such as suitability, usability, and acceptability of the DHIs and motivation, capability, and opportunity for the CYP using DHIs. The literature highlighted that CYP prefer DHIs with features such as videos, limited text, ability to personalize, ability to connect with others, and options to receive text message reminders. The findings of this review suggest a high average retention rate of 79% in studies involving various DHIs.

CONCLUSIONS

The development of DHIs is increasing and may be of interest to CYP, particularly in the area of MH treatment. With continuous technological advancements, it is important to know which modalities may increase engagement and help CYP who are facing MH problems. This review identified the existing modalities and highlighted the influencing factors from the perspective of CYP. This knowledge provides information that can be used to design and evaluate new interventions and offers important theoretical insights into how and why CYP engage in DHIs.

Is Digital Treatment the Holy Grail? Literature Review on Computerized and Blended Treatment for Depressive Disorders in Youth

Computerized and blended treatments seem to be an attractive treatment for adolescents as an alternative to face-to-face treatment, but mental health professionals seem hesitant to use these treatment modalities. This review provides an overview of factors contributing to and withholding from using computerized or blended treatment in routine care. Three databases were searched with terms related to (1) adolescents, (2) depression, (3) computerized or blended, and (4) treatment. Of the 33 articles identified, 10 focused on unguided computerized treatments, six on guided, two on blended, two compared unguided, blended- and face-to-face treatment to no treatment, and eight studies on games. Further, two articles that were focused on an online monitoring tool and three on intervention characteristics or preferred modes of help-seeking. Evidence for effectiveness, adherence, drop-out, and forming therapeutic relations were suspected to be barriers, but are no reason to reject computerized or blended treatment. Improvement in mental health literacy and the possibility to tailor the intervention are facilitators. However, adolescents' intention to seek help, acceptability of computerized treatment, symptom severity, time spent by therapist, and other facilities are identified as barriers and they need to be taken into account when using computerized or blended interventions. Nevertheless, computerized and blended are promising treatments for depressed youth.

Evaluating the Efficacy of Internet-Delivered Cognitive Behavioral Therapy Blended With Synchronous Chat Sessions to Treat Adolescent Depression: Randomized Controlled Trial

Background

Depression is a common and serious problem among adolescents, but few seek or have access to therapy. Internet-delivered cognitive behavioral therapies (ICBTs), developed to increase treatment access, show promise in reducing depression. The inclusion of coach support in treatment is desired and may be needed.

Objective

The aim of this study was to determine the efficacy of an ICBT protocol blended with weekly real-time therapist sessions via chat; blended treatment, for adolescent depression, including major depressive episode (MDE). The protocol has previously been evaluated in a controlled study.

Methods

In a two-arm randomized controlled trial, adolescents 15 to 19 years of age were recruited through a community setting at the national level in Sweden (n=70) and allocated to either 8 weeks of treatment or to minimal attention control. Depression was assessed at baseline, at posttreatment, and at 12 months following treatment (in the intervention group). The primary outcome was self-reported depression level as measured with the Beck Depression Inventory II at posttreatment. The intervention was offered without the need for parental consent.

Results

Over two weeks, 162 adolescents registered and completed the baseline screening. Eligible participants (n=70) were on average 17.5 years of age (SD 1.15), female (96%, 67/70), suffered from MDE (76%, 53/70), had no previous treatment experience (64%, 45/70), and reported guardian(s) to be aware about their depression state (71%, 50/70). The average intervention completion was 74% (11.8 of 16 modules and sessions). Following the treatment, ICBT participants demonstrated a significant decrease in depression symptoms compared with controls (P<.001), corresponding to a large between-group effect (intention-to-treat analysis: d=0.86, 95% CI 0.37-1.35; of completer analysis: d=0.99, 95% CI 0.48-1.51). A significant between-group effect was observed in the secondary depression outcome (P=.003); clinically significant improvement was found in 46% (16/35) of ICBT participants compared with 11% (4/35) in the control group (P=.001).

Conclusions

The results are in line with our previous study, further demonstrating that adolescents with depression can successfully be engaged in and experience significant improvement following ICBT blended with therapist chat sessions. Findings on participants’ age and baseline depression severity are of interest in relation to used study methods.

Trial Registration

ClinicalTrials.gov NCT02363205; https://clinicaltrials.gov/ct2/show/NCT02363205

Interventions for common mental health problems among university and college students: A systematic review and meta-analysis of randomized controlled trials

Common mental health problems (CMHPs), such as depression, anxiety disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD) are internalizing disorders with high comorbidity. University and college students are under many stressors and transitional events, and students fall within the age range when CMHPs are at their developmental peak. Compared to the expanded effort to explore and treat CMHPs, there has been no a meta-analysis that comprehensively reviewed the interventions for CMHPs and examined the effects of interventions for CMHPs in college students. The objective of this review is to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) examining interventions for CMHPs among university and college students and to estimate their post-intervention effect size (ES), as well as follow-up ES, for depression, anxiety disorder, OCD and PTSD separately. Meta-analytic procedures were conducted in accordance with PRISMA guidelines. We reviewed 7768 abstracts from which 331 full-text articles were reviewed and 51 RCTs were included in the analysis. We found moderate effect sizes for both depression (Hedges' g = -0.60) and anxiety disorder (Hedges' g = -0.48). There was no evidence that existing interventions for OCD or PTSD were effective in this population. For interventions with high number of papers, we performed subgroup analysis and found that cognitive behavioral therapy (CBT) and mindfulness-based interventions were effective for both depression and generalized anxiety disorder (GAD), and attention/perception modification was effective for GAD; other interventions (i.e. art, exercise and peer support) had the highest ES for both depression and GAD among university and college students.

Does providing a brief internet intervention for hazardous alcohol use to people seeking online help for depression reduce both alcohol use and depression symptoms among participants with these co-occurring disorders? Study protocol for a randomised controlled trial

INTRODUCTION

Hazardous alcohol consumption is common among people experiencing depression, often acting to exacerbate depressive symptoms. While many people with these co-occurring disorders do not seek face-to-face treatment, they do seek help online. There are effective internet interventions that target hazardous alcohol consumption or depression separately but none that combine these online interventions without the involvement of a therapist. In order to realise the potential of internet interventions, we need to develop an evidence base supporting the efficacy of internet interventions for co-occurring depression and hazardous alcohol use without any therapist involvement. This study aims to evaluate the effects on drinking, and on depressive symptoms, of combining an internet intervention targeting hazardous alcohol consumption with one for depression.

METHODS AND ANALYSIS

A double blinded, parallel group randomised controlled trial will be used. Participants with current depression who also drink in a hazardous fashion (n=986) will be recruited for a study to 'help improve an online intervention for depression'. Participants will be randomised either to receive an established online intervention for depression (MoodGYM) or to receive MoodGYM plus a brief internet intervention for hazardous alcohol consumption (Check Your Drinking; CYD). Participants will be contacted 3 and 6 months after receiving the interventions to assess changes in drinking and depression symptoms. It is predicted that participants receiving the CYD intervention in addition to MoodGYM will report greater postintervention reductions in alcohol consumption and depressive symptoms compared with those who received MoodGYM only. Hypothesised mediation and moderation effects will also be investigated. Using an intention-to-treat basis for the analyses, the hypotheses will be tested using a generalised linear hypothesis framework, and longitudinal analyses will use either generalised linear mixed modelling or generalised estimating equation approach where appropriate.

ETHICS AND DISSEMINATION

This research comprises the crucial first steps in developing lower-cost and efficacious internet interventions for people suffering from depression who also drink in a hazardous fashion-promoting the widespread availability of care for those in need. This study has been approved by the standing ethics review committee of the Centre for Addiction and Mental Health, and findings will be disseminated in the form of at least one peer-reviewed article and presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT03421080; Pre-results.

Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis

During the last two decades, Internet-delivered cognitive behavior therapy (ICBT) has been tested in hundreds of randomized controlled trials, often with promising results. However, the control groups were often waitlisted, care-as-usual or attention control. Hence, little is known about the relative efficacy of ICBT as compared to face-to-face cognitive behavior therapy (CBT). In the present systematic review and meta-analysis, which included 1418 participants, guided ICBT for psychiatric and somatic conditions were directly compared to face-to-face CBT within the same trial. Out of the 2078 articles screened, a total of 20 studies met all inclusion criteria. Results showed a pooled effect size at post-treatment of Hedges g = .05 (95% CI, -.09 to .20), indicating that ICBT and face-to-face treatment produced equivalent overall effects. Study quality did not affect outcomes. While the overall results indicate equivalence, there have been few studies of the individual psychiatric and somatic conditions so far, and for the majority, guided ICBT has not been compared against face-to-face treatment. Thus, more research, preferably with larger sample sizes, is needed to establish the general equivalence of the two treatment formats.

How do eHealth Programs for Adolescents With Depression Work? A Realist Review of Persuasive System Design Components in Internet-Based Psychological Therapies

Background

Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT) have been delivered face-to-face. However, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based CBT and IPT involve therapeutic content, interaction between the user and the system, and different technological features embedded into the online program (eg, multimedia). Studies of Internet-based CBT and IPT for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the treatment conditions that influence therapy outcomes is important to designing and evaluating these novel therapies.

Objective

Our aim was to examine the technological and program delivery features of Internet-based CBT and IPT for adolescent depression and to document their potential relation to treatment outcomes and program use.

Methods

We performed a realist synthesis. We started with an extensive search of published and gray literature. We included intervention studies that evaluated Internet-based CBT or IPT for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the Mixed-Methods Appraisal Tool to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how Internet-based CBT and IPT, as technology-based systems, influence the attitudes and behaviors of system users. PSD components described for the therapies were linked to reported outcomes using a cross-case comparison method and thematic synthesis.

Results

We identified 19 Internet-based CBT programs in 59 documents. Of those, 71% (42/59) were of moderate to high quality. The PSD features surface credibility (competent “look and feel”), dialogue support (online program + in-person support), liking and similarity (esthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction, and adherence, as well as symptom and functional impairments.

Conclusions

When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction, and depression-related outcomes. Testing of these features using hypothesis-driven dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness.

Annual Research Review: Digital health interventions for children and young people with mental health problems - a systematic and meta-review

BACKGROUND

Digital health interventions (DHIs), including computer-assisted therapy, smartphone apps and wearable technologies, are heralded as having enormous potential to improve uptake and accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. It is generally assumed that DHIs will be preferred by children and young people (CYP) given their ubiquitous digital activity. However, it remains uncertain whether: DHIs for CYP are clinically and cost-effective, CYP prefer DHIs to traditional services, DHIs widen access and how they should be evaluated and adopted by mental health services. This review evaluates the evidence-base for DHIs and considers the key research questions and approaches to evaluation and implementation.

METHODS

We conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP. We also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last 3 years.

RESULTS

Twenty-one reviews were included in the meta-review. The findings provide some support for the clinical benefit of DHIs, particularly computerised cognitive behavioural therapy (cCBT), for depression and anxiety in adolescents and young adults. The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD. The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain, and evidence is lacking regarding the cost-effectiveness of DHIs.

CONCLUSIONS

Key methodological limitations make it difficult to draw definitive conclusions from existing clinical trials of DHIs. Issues include variable uptake and engagement with DHIs, lack of an agreed typology/taxonomy for DHIs, small sample sizes, lack of blinded outcome assessment, combining different comparators, short-term follow-up and poor specification of the level of human support. Research and practice recommendations are presented that address the key research questions and methodological issues for the evaluation and clinical implementation of DHIs for CYP.

Effectiveness of a freely available computerised cognitive behavioural therapy programme (MoodGYM) for depression: Meta-analysis

OBJECTIVE

To investigate the effectiveness of a freely available computerised cognitive behavioural therapy programme (MoodGYM) for depression (primary outcome), anxiety and general psychological distress in adults.

METHOD

We searched PsycINFO, CINAHL Plus, MEDLINE, EMBASE, Social Science Citation Index and references from identified papers. To assess MoodGYM's effectiveness, we conducted random effects meta-analysis of identified randomised controlled trials.

RESULTS

Comparisons from 11 studies demonstrated MoodGYM's effectiveness for depression symptoms at post-intervention, with a small effect size ( g = 0.36, 95% confidence interval: 0.17-0.56; I² = 78%). Removing the lowest quality studies ( k = 3) had minimal impact; however, adjusting for publication bias reduced the effect size to a non-significant level ( g = 0.17, 95% confidence interval: -0.01 to 0.38). Comparisons from six studies demonstrated MoodGYM's effectiveness for anxiety symptoms at post-intervention, with a medium effect size ( g = 0.57, 95% confidence interval: 0.20-0.94; I² = 85%). Although comparisons from six studies did not yield significance for MoodGYM's effectiveness for general psychological distress symptoms, the small effect size approached significance ( g = 0.34, 95% confidence interval: -0.04 to 0.68; I² = 79%). Both the type of setting (clinical vs non-clinical) and MoodGYM-developer authorship in randomised controlled trials had no meaningful influence on results; however, the results were confounded by the type of control deployed, level of clinician guidance, international region of trial and adherence to MoodGYM.

CONCLUSIONS

The confounding influence of several variables, and presence of publication bias, means that the results of this meta-analysis should be interpreted with caution. Tentative support is provided for MoodGYM's effectiveness for symptoms of depression and general psychological distress. The programme's medium effect on anxiety symptoms demonstrates its utility for people with this difficulty. MoodGYM benefits from its free accessibility over the Internet, but adherence rates can be problematic and at the extreme can fall below 10%. We conclude that MoodGYM is best placed as a population-level intervention that is likely to benefit a sizeable minority of its users.

Logging into therapy: Adolescent perceptions of online therapies for mental health problems

OBJECTIVES

This study describes adolescent attitudes towards online therapies and explores the factors that predict these attitudes.

METHOD

Australian adolescents (N = 217) were surveyed on their knowledge of, attitudes towards (including perceived problems, perceived benefits, and perceived helpfulness), recommended availability of, and intentions to use online therapies. In addition, demographic and clinical factors, factors relating to technology use, adolescents' mental health attitudes, and personality traits were also measured.

RESULTS

The findings suggested that 72.0% of adolescents would access an online therapy if they experienced a mental health problem and 31.9% would choose an online therapy over traditional face-to-face support. The most valued benefits of these programs included alleviation of stigma and increased accessibility. Knowledge of online therapies was found to positively predict perceived helpfulness and intended uptake.

CONCLUSIONS

This study provides insight into adolescent attitudes towards online therapies and highlights the need to investigate strategies for increasing uptake.

Electronic interventions for depression in adolescents: hot idea or hot air?

Depressive disorders frequently onset in adolescence, and although effective treatments for these disorders are known, many youth have difficulty accessing care when needed. Electronic interventions and mobile applications have been posited as a possible solution for increasing access to affordable care. This narrative review explores the state of the evidence for their effectiveness, safety, and acceptability with teenagers. Although many electronic interventions and mobile applications have received widespread attention, minimal rigorous independent research has been conducted, and their use with teenagers who have depression cannot be recommended at this time.

Reduced Contact Cognitive-Behavioral Interventions for Adult Depression: A Review

Depression is a highly prevalent and debilitating mental health condition. Evidence suggests that there is a widening gap between the demand for and availability of effective treatments. As such, there is a vast need for the development and dissemination of accessible and affordable treatments for depression. In the past decade, there has been a proliferation of reduced client-therapist contact protocols for depression. In this article, the authors review and compare the efficacy of reduced contact cognitive-behavioral interventions for adult depression across two degrees of therapist-client contact (i.e., no therapist-client contact versus minimal therapist-client contact interventions). The authors also discuss the methodological and theoretical limitations of this research base. The present review suggests that a) reduced contact interventions for depression can be effective in remediating the symptoms of depression; b) the effect sizes of some reduced contact protocols may approximate those reported in traditional protocols involving significantly greater client-therapist contact; and c) protocols which employ some form of client-therapist contact, on average, generate higher effect sizes than those that are purely self-help in nature. A discussion of the theoretical and applied implications of such findings, as well as areas in need of further research, is provided.

Computerized Cognitive Behavior Therapy for Anxiety and Depression in Rural Areas: A Systematic Review

Background

People living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as cognitive behavior therapy (CBT), than their urban counterparts. Computerized CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners.

Objective

To systematically review the global evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations.

Methods

We searched seven online databases: Medline, Embase Classic and Embase, PsycINFO, CINAHL, Web of Science, Scopus, and the Cochrane Library. We also hand searched reference lists, Internet search engines, and trial protocols. Two stages of selection were undertaken. In the first, the three authors screened citations. Studies were retained if they reported the efficacy, effectiveness or acceptability of CCBT for depression and/or anxiety disorders, were peer reviewed, and written in English. The qualitative data analysis software, NVivo 10, was then used to run automated text searches for the word “rural,” its synonyms, and stemmed words. All studies identified were read in full and were included in the study if they measured or meaningfully discussed the efficacy or acceptability of CCBT among rural participants.

Results

A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated efficacy data by location of participant reported that CCBT was equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural than urban participants—studies to date showed that rural participants were less likely to want more face-to-face contact with a practitioner and found that computerized delivery addressed confidentiality concerns.

Conclusions

CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results across a wider range of countries, and to determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities.

Exploring the efficacy and acceptability of Internet-delivered cognitive behavioural therapy for young adults with anxiety and depression: an open trial

BACKGROUND

The highest prevalence of mental health problems is amongst people aged 18-24, with anxiety disorders and depression the most common disorders in this age group. Few young adults seek and receive effective care, prompting calls for the development of 'youth friendly' services. The Internet is a modality that has the potential to facilitate engagement with, and delivery of psychological treatments to, young adults. To date, however, no therapist-guided Internet-delivered treatments have been developed specifically for young adults experiencing depression and anxiety.

AIMS

To examine the efficacy and acceptability of a new therapist-guided Internet-delivered treatment for young adults aged 18-24 with symptoms of depression and anxiety.

METHOD

Participants accessed the Mood Mechanic Course, which consisted of four lessons delivered over 5 weeks. Measures of depression, anxiety, distress and disability were gathered before and after treatment, and at 3-month follow-up. Results were provided by 78% and 83% of participants at post-treatment and 3-month follow-up, respectively. Data were analysed using mixed linear model analyses. The trial was registered as: ACTRN12612001099819.

RESULTS

Treatment significantly reduced depression and anxiety symptom severity, disability and distress at post-treatment and 3-month follow-up. Large within-group effect sizes were found at post-treatment and 3-month follow-up on all measures using both completer and estimated marginal means (Cohen's d = 1.02 to 1.41 and 0.94 to 1.45, respectively). The therapist spent an average of 37 minutes (SD = 18 minutes) in contact with participants during treatment. Participants rated the treatment as acceptable.

CONCLUSIONS

Treatment gains recorded at post-treatment were sustained at 3-month follow-up, and were consistent with those reported in meta-analyses of Internet-delivered treatments developed for the broader adult population with depression and anxiety. These results provide encouraging preliminary evidence for the efficacy of therapist-guided Internet-delivered treatments for anxiety and depression tailored for young adults.