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Bjornstad G, Sonthalia S, Rouse B, Freeman L, Hessami N, Dunne JH, Axford N. A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1376. [PMID: 38188230 PMCID: PMC10771715 DOI: 10.1002/cl2.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/03/2023] [Indexed: 01/09/2024]
Abstract
Background Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities. Objectives The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability). Search Methods The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases. Selection Criteria Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included. Data Collection and Analysis Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models. Main Results Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations. Authors' Conclusions At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.
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Affiliation(s)
- Gretchen Bjornstad
- NIHR Applied Research Collaboration South West Peninsula (PenARC)University of Exeter Medical SchoolExeterUK
- Dartington Service Design LabBuckfastleighUK
| | - Shreya Sonthalia
- Dartington Service Design LabBuckfastleighUK
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowGlasgowUK
| | - Benjamin Rouse
- Center for Clinical Evidence and Guidelines, ECRI InstitutePlymouth MeetingPennsylvaniaUSA
| | | | | | - Jo Hickman Dunne
- The Centre for Youth ImpactLondonUK
- University of ManchesterManchesterUK
| | - Nick Axford
- NIHR Applied Research Collaboration South West Peninsula (PenARC)University of PlymouthPlymouthUK
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Hirao K, Takahashi H, Kuroda N, Uchida H, Tsuchiya K, Kikuchi S. Differences in Center for Epidemiologic Studies Depression Scale, Generalized Anxiety Disorder-7 and Kessler Screening Scale for Psychological Distress Scores between Smartphone Version versus Paper Version Administration: Evidence of Equivalence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4773. [PMID: 36981682 PMCID: PMC10049019 DOI: 10.3390/ijerph20064773] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
The use of electronic patient-reported outcomes has increased recently, and smartphones offer distinct advantages over other devices. However, previous systematic reviews have not investigated the reliability of the Center for Epidemiologic Studies Depression Scale (CES-D), Generalized Anxiety Disorder-7 (GAD-7), and Kessler Screening Scale for Psychological Distress (K6) when used with smartphones, and this has not been fully explored. This study aimed to evaluate the equivalence of the paper and smartphone versions of the CES-D, GAD-7, and K6, which were compared following a randomized crossover design method in 100 adults in Gunma, Japan. Participants responded to the paper and smartphone versions at 1-week intervals. The equivalence of paper and smartphone versions was evaluated using the intraclass correlation coefficient (ICCagreement). The mean participant age was 19.86 years (SD = 1.08, 23% male). The ICCagreements for the paper and smartphone versions of the CES-D, GAD-7, and K6 were 0.76 (95% confidence interval [CI] 0.66-0.83), 0.68 (95% CI 0.59-0.77), and 0.83 (95% CI 0.75-0.88), respectively. Thus, the CES-D and K6 scales are appropriate for use in a smartphone version, which could be applied to clinical and research settings in which the paper or smartphone versions could be used as needed.
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Affiliation(s)
- Kazuki Hirao
- Graduate School of Health Sciences, Gunma University, Maebashi 371-8514, Japan
- Department of Occupational Therapy, Faculty of Medicine, Gunma University, Maebashi 371-8514, Japan
| | - Hyono Takahashi
- Department of Occupational Therapy, Faculty of Medicine, Gunma University, Maebashi 371-8514, Japan
| | - Natsuki Kuroda
- Department of Occupational Therapy, Faculty of Medicine, Gunma University, Maebashi 371-8514, Japan
| | - Hiroyuki Uchida
- Department of Rehabilitation, Kurashiki Heisei Hospital, Kurashiki 710-0826, Japan
| | - Kenji Tsuchiya
- Department of Rehabilitation, Faculty of Health Sciences, Nagano University of Health and Medicine, Nagano 381-2227, Japan
| | - Senichiro Kikuchi
- Graduate School of Health Sciences, Gunma University, Maebashi 371-8514, Japan
- Department of Occupational Therapy, Faculty of Medicine, Gunma University, Maebashi 371-8514, Japan
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Effectiveness of a Comprehensive Mental Health Literacy Educational Programme for Junior High School Students: A Randomised Controlled Trial Examining Changes in Their Knowledge, Attitudes, and Behaviour. J Pers Med 2022; 12:jpm12081281. [PMID: 36013230 PMCID: PMC9410060 DOI: 10.3390/jpm12081281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/24/2022] [Accepted: 08/02/2022] [Indexed: 12/22/2022] Open
Abstract
Background: This study evaluated the effectiveness of a comprehensive mental health literacy (MHL) educational programme known as “Sanita” for improving junior high school students’ knowledge of mental illness, attitudes towards people with mental health problems, and help-seeking behaviour. Methods: A randomised controlled trial with a parallel-group design was conducted. A total of 125 students (51 in the intervention group and 74 in the control group) received three 50-min classes and completed self-report questionnaires (Mental Illness and Disorder Understanding Scale, MIDUS; Reported and Intended Behaviour Scale, RIBS-J; and an original questionnaire investigating help-seeking behaviour) before and after the programme and three months later. Results: Regarding MIDUS, the post-test and 3-month follow-up test results showed a significant main effect of time-by-group interactions in a linear mixed model. Regarding RIBS-J, the post-test results showed a significant main effect of time-by-group interactions; however, the 3-month follow-up test showed no significant effect. No significant effects of time-by-group interactions were seen in the post-test and 3-month follow-up test results for help-seeking behaviour in a logistic regression-mixed model. Conclusions: The Sanita MHL educational programme was longitudinally effective at improving junior high school students’ knowledge of mental illness, although improvements in attitudes and help-seeking behaviour were insufficient.
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Breslin G, Shannon S, Cummings M, Leavey G. An updated systematic review of interventions to increase awareness of mental health and well-being in athletes, coaches, officials and parents. Syst Rev 2022; 11:99. [PMID: 35590425 PMCID: PMC9118780 DOI: 10.1186/s13643-022-01932-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/18/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Interventions designed to increase mental health awareness in sport have grown substantially in the last 5 years, meaning that those involved in policy, research and intervention implementation are not fully informed by the latest systematic evaluation of research, risking a disservice to healthcare consumers. Hence, our aim was to update a 2017 systematic review that determined the effect of sport-specific mental health awareness programmes to improve mental health knowledge and help-seeking among sports coaches, athletes and officials. We extended the review to incorporate parents as a source of help-seeking and report the validity of outcome measures and quality of research design that occurred since the original review. METHODS Sport-specific mental health awareness programmes adopting an experimental or quasi-experimental design were included for synthesis. Five electronic databases were searched: Psychinfo, Medline (OVID interface), Scopus, Cochrane and Cinahl. Each database was searched from its year of inception to June 2020. As all of the outcomes measured were derived from psychometric scales, we observed statistically significant quantitative effects on the basis of p < .05, and a small, medium or large effect size as d = .2, .5 or .8, respectively. Risk of bias was assessed using the Cochrane and QATSQ tools. RESULTS Twenty-eight articles were included from the 2048 retrieved, eighteen additional articles since the original review. Eighteen studies targeted athletes, five with coaches, one sport officials (i.e. referees), one 'at-risk children' and three with parents. One of the studies was a combination of athletes, coaches and parents. In terms of study outcomes, health referral efficacy was improved in seven studies; twelve studies reported an increase in knowledge about mental health disorders. Proportionally, higher quality research designs were evident, as three of ten studies within the previous review did not demonstrate a high risk of bias, whereas thirteen of the eighteen additional studies did not display a high risk of bias. However, only one study included a behaviour change model in both the programme design and evaluation. CONCLUSIONS Our updated systematic review provides evidence of the benefits of mental health awareness interventions in sport; these benefits are mainly for athletes and show improvements in the methodological design of recent studies compared to the first review. There was also evidence of the extension of programme delivery to parents. In conclusion, researchers, practitioners and policy makers should consider methodological guidance and the application of theory when developing and evaluating complex interventions. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016040178.
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Affiliation(s)
- Gavin Breslin
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Cromore Road, Coleraine, BT52 1SA, Northern Ireland
| | - Stephen Shannon
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Cromore Road, Coleraine, BT52 1SA, Northern Ireland. .,Sport and Exercise Sciences Research Institute, Ulster University Jordanstown Campus, Newtownabbey, Northern Ireland.
| | - Michael Cummings
- Maastricht University, Minderbroedersberg 4-6, Maastricht, 6211 LK, The Netherlands
| | - Gerard Leavey
- Bamford Centre for Mental Health and Wellbeing, School of Psychology, Ulster University, Cromore Road, Coleraine, BT52 1SA, Northern Ireland
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Wickersham A, Barack T, Cross L, Downs J. Computerized Cognitive Behavioral Therapy for Treatment of Depression and Anxiety in Adolescents: Systematic Review and Meta-analysis. J Med Internet Res 2022; 24:e29842. [PMID: 35404263 PMCID: PMC9039813 DOI: 10.2196/29842] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/30/2021] [Accepted: 12/03/2021] [Indexed: 12/21/2022] Open
Abstract
Background
Depression and anxiety are major public health concerns among adolescents. Computerized cognitive behavioral therapy (cCBT) has emerged as a potential intervention, but its efficacy in adolescents remains unestablished.
Objective
This review aimed to systematically review and meta-analyze findings on the efficacy of cCBT for the treatment of adolescent depression and anxiety.
Methods
Embase, PsycINFO, and Ovid MEDLINE were systematically searched for randomized controlled trials in English, which investigated the efficacy of cCBT for reducing self-reported depression or anxiety in adolescents aged 11 to 19 years. Titles, abstracts, and full texts were screened for eligibility by 2 independent researchers (TB and LC). A random-effects meta-analysis was conducted to pool the effects of cCBT on depression and anxiety symptom scores compared with the control groups. Study quality was assessed using the Cochrane Collaboration Risk of Bias tool.
Results
A total of 16 randomized controlled trials were eligible for inclusion in this review, of which 13 (81%) were included in the meta-analysis. The quality of the studies was mixed, with 5 (31%) studies rated as good overall, 2 (13%) rated as fair, and 9 (56%) rated as poor. Small but statistically significant effects of cCBT were detected, with cCBT conditions showing lower symptom scores at follow-up compared with control conditions for both anxiety (standardized mean difference −0.21, 95% CI −0.33 to −0.09; I2=36.2%) and depression (standardized mean difference −0.23, 95% CI −0.39 to −0.07; I2=59.5%). Secondary analyses suggested that cCBT may be comparable with alternative, active interventions (such as face-to-face therapy or treatment as usual).
Conclusions
This meta-analysis reinforces the efficacy of cCBT for the treatment of anxiety and depression and is the first to examine this exclusively in adolescents. Future research could aim to identify the active components of these interventions toward optimizing their development and increasing the feasibility and acceptability of cCBT in this age group.
Trial Registration
PROSPERO CRD42019141941; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141941
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Affiliation(s)
- Alice Wickersham
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Tamara Barack
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Lauren Cross
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Johnny Downs
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
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Ojio Y, Matsunaga A, Hatakeyama K, Kawamura S, Horiguchi M, Baron D, Fujii C. Developing a Japanese Version of the Baron Depression Screener for Athletes among Male Professional Rugby Players. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155533. [PMID: 32751819 PMCID: PMC7432524 DOI: 10.3390/ijerph17155533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 12/18/2022]
Abstract
The Baron Depression Screener for Athletes (BDSA) is a brief, valid, and reliable athlete- specific assessment tool developed in the US to assess depressive symptoms in elite athletes. We examined the applicability and reliability of a Japanese version of the BDSA (BDSA-J) in a Japanese context, and further examined the construct validity of the BDSA-J. Web-based anonymous self-report data of 235 currently competing Japanese professional male rugby players (25–29 years = 123 [52.3%]) was analyzed. A two-stage process was conducted to validate the factor structure of the BDSA-J using exploratory factor analysis in a randomly partitioned calibration sample, and confirmatory factor analysis in a separate validation sample. Cronbach’s alpha was used to assess internal consistency. Spearman’s rank-order correlation coefficients were calculated to examine convergent validity with the Kessler-6. We identified a one-factor structure for BDSA-J. Confirmatory factor analysis supported this one-factor model, revealing good model fit indices. The standardized path coefficients for each of the items were β = 0.52 to 0.79 (p < 0.001). A Cronbach’s alpha of 0.71 was obtained for the BDSA-J. BDSA-J showed significant positive correlations with the Kessler-6. The BDSA-J is an appropriate and psychometrically robust measure for identifying depressive symptoms in Japanese male rugby players.
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Affiliation(s)
- Yasutaka Ojio
- Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
- Correspondence: ; Tel.: +81-(0)42-346-2168; Fax: +81-(0)42-346-2169
| | - Asami Matsunaga
- Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
| | | | - Shin Kawamura
- Japan Rugby Players Association, Tokyo 108-0074, Japan
| | | | - David Baron
- Senior Vice President and Provost, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Chiyo Fujii
- Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
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Gwyther K, Swann R, Casey K, Purcell R, Rice SM. Developing young men's wellbeing through community and school-based programs: A systematic review. PLoS One 2019; 14:e0216955. [PMID: 31107908 PMCID: PMC6527294 DOI: 10.1371/journal.pone.0216955] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/01/2019] [Indexed: 11/19/2022] Open
Abstract
Boys and young men have unique health-related needs that may be poorly met by existing programs and initiatives. The mismatch between the needs of boys and young men and current service offerings-driven largely by social determinants of health such as masculinity-may stymie health status. This is evidenced through high rates of self-stigma, accidental death or suicide, and low rates of help seeking and health literacy among populations of boys and young men. With growing interest in improving wellbeing and educational outcomes for all young people (including boys and young men), this systematic review aimed to evaluate community and school-based programs with specific focus on program features and outcomes directly relevant to young males aged 12-25 years. Five data-bases were searched; Medline, EMBASE, PsycInfo, ERIC, and ERAD. Articles were included if they evaluated an intervention or program with a general or at-risk sample of young men, and measured a psychological, psychosocial, masculinity, or educational outcome. The majority of the 40 included studies had high quality reporting (62.5%). Synthesised data included theoretical frameworks, intervention characteristics, outcomes, and key results. Of the included studies, 14 were male-focussed programs, with masculinity approaches directed towards program aims and content information. The emergent trend indicated that male-targeted interventions may be more beneficial for young men than gender-neutral programs, however, none of these studies incorporated masculine-specific theory as an overarching framework. Furthermore, only three studies measured masculine-specific variables. Studies were limited by a lack of replication and program refinement approaches. It is concluded that there is significant scope for further development of community and school-based health promotion programs that target young men through incorporation of frameworks that consider the impact of gendered social and environmental determinants of health. Evaluation of these programs will provide researchers and practitioners with the capacity for translating beneficial outcomes into best-practice policy.
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Affiliation(s)
- Kate Gwyther
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, the University of Melbourne, Victoria, Australia
| | - Ray Swann
- Crowther Centre, Brighton Grammar School, Melbourne, Victoria, Australia
| | - Kate Casey
- Crowther Centre, Brighton Grammar School, Melbourne, Victoria, Australia
| | - Rosemary Purcell
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, the University of Melbourne, Victoria, Australia
| | - Simon M. Rice
- Orygen, the National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, the University of Melbourne, Victoria, Australia
- Youth Mood Clinic, Orygen Youth Health, Melbourne, Victoria, Australia
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Garrido S, Millington C, Cheers D, Boydell K, Schubert E, Meade T, Nguyen QV. What Works and What Doesn't Work? A Systematic Review of Digital Mental Health Interventions for Depression and Anxiety in Young People. Front Psychiatry 2019; 10:759. [PMID: 31798468 PMCID: PMC6865844 DOI: 10.3389/fpsyt.2019.00759] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background: A major challenge in providing mental health interventions for young people is making such interventions accessible and appealing to those most in need. Online and app-based forms of therapy for mental health are burgeoning. It is therefore crucial to identify features that are most effective and engaging for young users. Objectives: This study reports a systematic review and meta-analysis of digital mental health interventions and their effectiveness in addressing anxiety and depression in young people to determine factors that relate to outcomes, adherence, and engagement with such interventions. Methods: A mixed methods approach was taken, including a meta-analysis of 9 randomized controlled trials that compared use of a digital intervention for depression in young people to a no-intervention control group, and 6 comparing the intervention to an active control condition. A thematic analysis and narrative synthesis of 41 studies was also performed. Results: The pooled effect size of digital mental health interventions on depression in comparison to a no-intervention control was small (Cohen's d = 0.33, 95% CI 0.11 to 0.55), while the pooled effect size of studies comparing an intervention group to an active control showed no significant differences (Cohen's d = 0.14, 95% CI -.04 to 0.31). Pooled effect sizes were higher when supervision was involved (studies with no-intervention controls: Cohen's d = 0.52, 95% CI 0.23 to 0.80; studies with active control: Cohen's d = 0.49, 95% CI -0.11, 1.01). Engagement and adherence rates were low. Qualitative analysis revealed that users liked interventions with a game-like feel and relatable, interactive content. Educational materials were perceived as boring, and users were put off by non-appealing interfaces and technical glitches. Conclusions: Digital interventions work better than no intervention to improve depression in young people when results of different studies are pooled together. However, these interventions may only be of clinical significance when use is highly supervised. Digital interventions do not work better than active alternatives regardless of the level of support. Future interventions need to move beyond the use of digital educational materials, considering other ways to attract and engage young people and to ensure relevance and appeal.
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Affiliation(s)
- Sandra Garrido
- MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Milperra, NSW, Australia.,Translational Health Institute, Western Sydney University, Campbelltown, NSW, Australia.,School of Social Sciences & Psychology, Western Sydney University, Milperra, NSW, Australia
| | - Chris Millington
- MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Milperra, NSW, Australia
| | - Daniel Cheers
- MARCS Institute for Brain, Behaviour & Development, Western Sydney University, Milperra, NSW, Australia.,NSW Health, Sydney, NSW, Australia
| | | | - Emery Schubert
- School of Arts & Humanities, University of New South Wales, Kensington, NSW, Australia
| | - Tanya Meade
- School of Social Sciences & Psychology, Western Sydney University, Milperra, NSW, Australia
| | - Quang Vinh Nguyen
- School of Computing & Engineering, Western Sydney University, Parramatta, NSW, Australia
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Nakao S, Nakagawa A, Oguchi Y, Mitsuda D, Kato N, Nakagawa Y, Tamura N, Kudo Y, Abe T, Hiyama M, Iwashita S, Ono Y, Mimura M. Web-Based Cognitive Behavioral Therapy Blended With Face-to-Face Sessions for Major Depression: Randomized Controlled Trial. J Med Internet Res 2018; 20:e10743. [PMID: 30249583 PMCID: PMC6231848 DOI: 10.2196/10743] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/02/2018] [Accepted: 08/14/2018] [Indexed: 01/20/2023] Open
Abstract
Background Meta-analyses of several randomized controlled trials have shown that cognitive behavioral therapy (CBT) has comparable efficacy to antidepressant medication, but therapist availability and cost-effectiveness is a problem. Objective This study aimed to evaluate the effectiveness of Web-based CBT blended with face-to-face sessions that reduce therapist time in patients with major depression who were unresponsive to antidepressant medications. Methods A 12-week, assessor-masked, parallel-group, waiting- list controlled, randomized trial was conducted at 3 medical institutions in Tokyo. Outpatients aged 20-65 years with a primary diagnosis of major depression who were taking ≥1 antidepressant medications at an adequate dose for ≥6 weeks and had a 17-item GRID-Hamilton Depression Rating Scale (HAMD) score of ≥14 were randomly assigned (1:1) to blended CBT or waiting-list groups using a computer allocation system, stratified by the study site with the minimization method, to balance age and baseline GRID-HAMD score. The CBT intervention was given in a combined format, comprising a Web-based program and 12 45-minute face-to-face sessions. Thus, across 12 weeks, a participant could receive up to 540 minutes of contact with a therapist, which is approximately two-thirds of the therapist contact time provided in the conventional CBT protocol, which typically provides 16 50-minute sessions. The primary outcome was the alleviation of depressive symptoms, as measured by a change in the total GRID-HAMD score from baseline (at randomization) to posttreatment (at 12 weeks). Moreover, in an exploratory analysis, we investigated whether the expected positive effects of the intervention were sustained during follow-up, 3 months after the posttreatment assessment. Analyses were performed on an intention-to-treat basis, and the primary outcome was analyzed using a mixed-effects model for repeated measures. Results We randomized 40 participants to either blended CBT (n=20) or waiting-list (n=20) groups. All patients completed the 12-week treatment protocol and were included in the intention-to-treat analyses. Participants in the blended CBT group had significantly alleviated depressive symptoms at week 12, as shown by greater least squares mean changes in the GRID-HAMD score, than those in the waiting list group (−8.9 points vs −3.0 points; mean between-group difference=−5.95; 95% CI −9.53 to −2.37; P<.001). The follow-up effects within the blended CBT group, as measured by the GRID-HAMD score, were sustained at the 3-month follow-up (week 24) and posttreatment (week 12): posttreatment, 9.4 (SD 5.2), versus follow-up, 7.2 (SD 5.7); P=.009. Conclusions Although our findings warrant confirmation in larger and longer term studies with active controls, these suggest that a combined form of CBT is effective in reducing depressive symptoms in patients with major depression who are unresponsive to antidepressant medications. Trial Registration University Hospital Medical Information Network Clinical Trials Registry: UMIN000009242; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000010852 (Archived by WebCite at http://www.webcitation. org/729VkpyYL)
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Affiliation(s)
- Shigetsugu Nakao
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Atsuo Nakagawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan.,National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, Kodaira, Japan.,Department of Psychiatry, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Department of Psychiatry, Sakuragaoka Memorial Hospital, Tama, Japan
| | - Yoshiyo Oguchi
- Department of Psychiatry, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Dai Mitsuda
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Kato
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.,National Center for Cognitive Behavior Therapy and Research, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Yuko Nakagawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Tamura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yuka Kudo
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takayuki Abe
- Clinical and Translational Research Center, Keio University Hospital, Tokyo, Japan.,Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Mitsunori Hiyama
- Department of Psychiatry, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoru Iwashita
- Department of Psychiatry, Sakuragaoka Memorial Hospital, Tama, Japan
| | - Yutaka Ono
- Center for the Development of Cognitive Behavior Therapy Training, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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