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Grudin R, Vigerland S, Ahlen J, Widström H, Unger I, Serlachius E, Engberg H. "Therapy without a therapist?" The experiences of adolescents and their parents of online behavioural activation for depression with and without therapist support. Eur Child Adolesc Psychiatry 2024; 33:105-114. [PMID: 36650254 PMCID: PMC9844942 DOI: 10.1007/s00787-023-02142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
Behavioural Activation (BA) is an established treatment for adults with depression, and research on BA for adolescents is promising. However, there is a knowledge gap in terms of the experiences of adolescents and their parents BA for depression delivered online. Furthermore, there have been no previous studies conducted on the experiences of respondents with regard to the role of the therapist in online treatment. Therefore, the primary aim of this study is to explore the experiences of online BA among adolescents with depression and how their parents experience supporting their adolescent through treatment. Second, the experiences of having online therapy with or without a therapist were explored. Semi-structured interviews were conducted with eight adolescents and nine parents (n = 17) who completed guided or self-guided online BA. Reflexive thematic analysis was used to identify aspects of the experience of treatment that were important to adolescents and their parents. Two main themes were generated: (1) opportunities or barriers to engaging in treatment and (2) parental involvement is valued and welcomed. This study contributes valuable information regarding user experiences of BA treatment, the importance of therapist support and parental involvement in treating adolescents with depression.Trial registration number: ClinicalTrials.gov Identifier NCT04117789, Date of registration: 07 October 2019.
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Affiliation(s)
- Rebecca Grudin
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Healthcare Services, Region Stockholm, Gävlegatan 22, 113 30, Stockholm, Sweden.
| | - Sarah Vigerland
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Healthcare Services, Region Stockholm, Gävlegatan 22, 113 30, Stockholm, Sweden
| | - Johan Ahlen
- The Centre for Epidemiology and Community Medicine, Region Stockholm, Box 45436, 104 31, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Hanna Widström
- Moment Psychology, Drottninggatan 99, 113 60, Stockholm, Sweden
| | - Irma Unger
- Wemind Psychiatry, Rehnsgatan 20, 113 57, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Baravägen 1, 222 40, Lund, Sweden
| | - Hedvig Engberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
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Hollis C, Hall CL, Khan K, Le Novere M, Marston L, Jones R, Hunter R, Brown BJ, Sanderson C, Andrén P, Bennett SD, Chamberlain LR, Davies EB, Evans A, Kouzoupi N, McKenzie C, Heyman I, Kilgariff J, Glazebrook C, Mataix-Cols D, Serlachius E, Murray E, Murphy T. Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation. Health Technol Assess 2023; 27:1-120. [PMID: 37924247 PMCID: PMC10641713 DOI: 10.3310/cpms3211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023] Open
Abstract
Background Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online. Objective To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders. Design Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation. Setting Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals. Participants Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months. Interventions Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control). Outcome Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation. Results Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes. Harms Two serious, unrelated adverse events occurred in the control group. Limitations We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services. Conclusion Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months. Future work Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice. Trial registration This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Chris Hollis
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Institute of Mental Health, University of Nottingham, Nottingham, UK
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
- Department of Child and Adolescent Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, South Block Level E, Queen's Medical Centre, Nottingham, UK
| | - Charlotte L Hall
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Institute of Mental Health, University of Nottingham, Nottingham, UK
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Kareem Khan
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Marie Le Novere
- Research Department of Primary Care and Population Health and Priment CTU, University College London, London, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health and Priment CTU, University College London, London, UK
| | - Rebecca Jones
- Division of Psychiatry and Priment CTU, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health and Priment CTU, University College London, London, UK
| | - Beverley J Brown
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Charlotte Sanderson
- UCL Great Ormond Street Institute of Child Health (ICH), London, UK/Great Ormond Street Hospital for Children NHS Trust, London, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Per Andrén
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Sophie D Bennett
- UCL Great Ormond Street Institute of Child Health (ICH), London, UK/Great Ormond Street Hospital for Children NHS Trust, London, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liam R Chamberlain
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - E Bethan Davies
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Amber Evans
- UCL Great Ormond Street Institute of Child Health (ICH), London, UK/Great Ormond Street Hospital for Children NHS Trust, London, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Natalia Kouzoupi
- UCL Great Ormond Street Institute of Child Health (ICH), London, UK/Great Ormond Street Hospital for Children NHS Trust, London, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Caitlin McKenzie
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Isobel Heyman
- UCL Great Ormond Street Institute of Child Health (ICH), London, UK/Great Ormond Street Hospital for Children NHS Trust, London, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Joseph Kilgariff
- Department of Child and Adolescent Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, South Block Level E, Queen's Medical Centre, Nottingham, UK
| | - Cristine Glazebrook
- NIHR MindTech MedTech Co-operative, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, UK
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health and Priment CTU, University College London, London, UK
| | - Tara Murphy
- UCL Great Ormond Street Institute of Child Health (ICH), London, UK/Great Ormond Street Hospital for Children NHS Trust, London, UK
- Psychological and Mental Health Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Mamukashvili-Delau M, Koburger N, Dietrich S, Rummel-Kluge C. Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults With Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials. JMIR Ment Health 2023; 10:e46925. [PMID: 37606990 PMCID: PMC10481211 DOI: 10.2196/46925] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/20/2023] [Accepted: 07/11/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Depression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention. OBJECTIVE This systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life. METHODS The Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October). RESULTS The search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] -0.43, 95% CI -0.67 to -0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001). CONCLUSIONS This systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements.
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Affiliation(s)
- Megi Mamukashvili-Delau
- Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Nicole Koburger
- Department of Research and Transfer, Leipzig University, Leipzig, Germany
| | - Sandra Dietrich
- Leipzig Travel, Leipzig Tourismus und Marketing GmbH, Leipzig, Germany
| | - Christine Rummel-Kluge
- Department of Psychiatry and Psychotherapy, Medical Faculty, Leipzig University, Leipzig, Germany
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Leipzig, Leipzig, Germany
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Mamukashvili-Delau M, Koburger N, Dietrich S, Rummel-Kluge C. Efficacy of computer- and/or internet-based cognitive-behavioral guided self-management for depression in adults: a systematic review and meta-analysis of randomized controlled trials. BMC Psychiatry 2022; 22:730. [PMID: 36424570 PMCID: PMC9685980 DOI: 10.1186/s12888-022-04325-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Depression is a worldwide disease. CBT-based self-help treatment allows patients with mild to moderate depression symptoms to improve their depression or to bridge the waiting- or pandemic period until they receive further clinical treatment. OBJECTIVE This systematic review and meta-analysis aims to explore the efficacy, acceptability and improvement in quality of life of computer-delivered and/or internet-based CBT self-help interventions with minimal guidance (up to 10 min) for depression. The second aim was to compare the effectiveness of reducing depression symptoms at post-treatment of treatment by the type of minimal guidance: (1) e-mail, (2) telephone calls, (3) e-mail and telephone together, or (4) face-to-face. METHODS The Cochrane depression, anxiety, and neurosis review group's specialized register electronic searches, grey literature, reference lists and correspondence were used to search for published and unpublished RCTs that reported efficacy of computer- and/or internet-based CBT self-help treatments for depression with minimal guidance up to 10 min per week. Methodological quality of included studies was evaluated with Cochrane Collaboration tools for assessing risk of bias. The meta-analysis was accomplished using the RevMen software. RESULTS In total, 2809 study abstracts were checked for eligibility. Out of these, 19 studies (21 samples) with a total of 3226 participants were included. The results showed that concerning efficacy, the treatment group is superior to the control group with a medium to large effect size of 0.65. Also, treatment groups with combined guidance by e-mail and telephone calls together had greater effects (SMD -0.76) than groups with other types of minimal guidance (guided by e-mail SMD -0.63; guided face to-face SMD - 0.66; guided by telephone calls SMD -0.49). Findings showed also, that iCBT with minimal guidance had small but statistically significant effect size of 0.28 in improving quality of life. Moreover, there were higher drop-out rates in the treatment condition (RR 1.36) than in the control groups. CONCLUSIONS The results of this meta-analysis support the efficacy of computer- and/or internet-based CBT self-help programs with minimal weekly guidance up to only 10 min for improving depression symptoms at post-treatment for adults. In addition, the results are pointing towards two practical implications. Firstly, depressed persons can use self-help treatment with minimal guidance at home to improve their symptoms or to bridge the waiting time - or pandemic period - before they receive professional face-to-face treatment. Secondly, it can help clinicians to make the decision about using CBT-based self-help treatments for patients that do not need urgent professional treatment, or to combine it with face-to-face therapy.
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Affiliation(s)
- Megi Mamukashvili-Delau
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, Klinik Und Poliklinik Für Psychiatrie Und Psychotherapie, Medical Faculty, Leipzig University, Semmelweisstraße 10, Haus 13, 04103 Leipzig, Leipzig, Germany ,grid.411339.d0000 0000 8517 9062Department of Psychiatry and Psychotherapy, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Nicole Koburger
- grid.9647.c0000 0004 7669 9786Department of Personnel Development and Academic Personnel Development, Leipzig University, Leipzig, Germany
| | - Sandra Dietrich
- Leipzig Travel, Leipzig Tourismus and Marketing GmbH, Leipzig, Germany
| | - Christine Rummel-Kluge
- Department of Psychiatry and Psychotherapy, Klinik Und Poliklinik Für Psychiatrie Und Psychotherapie, Medical Faculty, Leipzig University, Semmelweisstraße 10, Haus 13, 04103, Leipzig, Leipzig, Germany. .,Department of Psychiatry and Psychotherapy, Universitätsklinikum Leipzig, Leipzig, Germany.
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Leone SS, Smeets O, Lokman S, Boon B, van der Poel A, Van Doesum T, Shields-Zeeman L, Kramer J, Smit F. Comparing a ses-sensitive and an all-ses implementation strategy to improve participation rates of patients with a lower socioeconomic background in a web-based intervention for depressive complaints: a cluster randomised trial in primary care. BMC PRIMARY CARE 2022; 23:205. [PMID: 35948866 PMCID: PMC9367024 DOI: 10.1186/s12875-022-01793-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/12/2022] [Indexed: 11/19/2022]
Abstract
Background Depression is a major public health concern, which is most pronounced in population segments with a lower social-economic status (SES). E-health interventions for depressive complaints are proven to be effective, but their reach needs to be improved, especially among people with a lower socioeconomic status (SES). Implementing e-health interventions in the primary care setting with SES-sensitive guidance from General Practice nurses (GP nurses) may be a useful strategy to increase the reach of e-health in lower SES groups. We implemented an evidence-based online intervention that targets depressive complaints in primary care. Methods A pragmatic cluster-randomised trial was conducted in two parallel groups where a SES sensitive (SES-sens) implementation strategy with additional face-to-face guidance by GP nurses was compared to an all-SES implementation strategy. The primary outcome was the percentage of lower SES participants in either condition. Participation was defined as completing at least 1 face-to-face session and 2 online exercises. Participation rates were evaluated using logistic mixed modelling. Results In both conditions, the participation rates of lower SES participants were quite high, but were notably lower in the SES-sens implementation condition (44%) than in the all-SES implementation condition (58%). This unexpected outcome remained statistically significant even after adjusting for potential confounders between the conditions (Odds Ratio 0.43, 95%-CI 0.22 to 0.81). Less guidance was provided by the GP nurses in the SES-sens group, contrary to the implementation instructions. Conclusions From a public health point of view, it is good news that a substantial number of primary care patients with a lower SES level used the implemented e-health intervention. It is also positive that an all-SES implementation strategy performed well, and even outperformed a SES-sensitive strategy. However, this was an unexpected finding, warranting further research into tailoring implementation strategies of e-health interventions towards specific target groups in the primary care setting. Trial registration Netherlands Trial Register, identifier: NL6595, registered on 12 November 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01793-w.
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Johnsen HM, Haddeland K. User evaluation of a therapist-guided internet-delivered treatment program for anxiety disorders: A qualitative study. Internet Interv 2021; 25:100389. [PMID: 33996506 PMCID: PMC8091870 DOI: 10.1016/j.invent.2021.100389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/27/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
Therapist-guided internet-based cognitive behaviour therapy (ICBT) has been proposed as a potential means to increase individuals' access to quality mental health care and effective treatment. Guided ICBT aims to increase a patient's knowledge and competence to better cope with their disorder. Despite the growing evidence supporting the effects of guided ICBT, there is remarkably little research on the different factors that are important for patients to achieve effects from using such digital treatment interventions. Thus, the aim of this study was to conduct a user evaluation of a therapist-guided ICBT program using the updated DeLone and McLean (D&M) model for measuring information systems (IS) success or effectiveness. This model includes the following six dimensions: system quality, information quality, service quality, intention to use and use, user satisfaction, and net benefits (impacts or effect). Ten users of a Norwegian therapist-guided ICBT program for treating anxiety disorders named 'Assisted Self-Help' (Assistert Selvhjelp) participated in phone-based individual interviews. Data were analysed using directed content analysis. Results showed that the participants were quite satisfied with the program's system quality and information quality. However, participants suggested improvements, including in-program instruction, improved visibility of system status, more flexibility regarding automated measurement surveys, and the inclusion of more videos with patient stories. Further, the results indicated a need for improvement in the service quality of guided ICBT introduction, instruction, follow-up, guidance, and support from therapists. The results showed that user friendliness and high educational content might not be sufficient for a therapist-guided ICBT program to be perceived as effective. It might also be necessary for therapists to provide follow-up, guidance, and support that are more in line with individual patient needs. Thus, the results suggest that guided ICBT requires active participation from all involved in the process, including the therapist.
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Affiliation(s)
- Hege Mari Johnsen
- Corresponding author at: Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, PO Box 509, 4898 Grimstad, Norway.
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Karyotaki E, Efthimiou O, Miguel C, Bermpohl FMG, Furukawa TA, Cuijpers P. Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis. JAMA Psychiatry 2021; 78:361-371. [PMID: 33471111 PMCID: PMC8027916 DOI: 10.1001/jamapsychiatry.2020.4364] [Citation(s) in RCA: 311] [Impact Index Per Article: 103.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/23/2020] [Indexed: 12/11/2022]
Abstract
Importance Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them. Objective To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information. Data Sources We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019. Study Selection Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization. Data Extraction and Synthesis We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression. Main Outcomes and Measures Patient Health Questionnaire-9 (PHQ-9) scores. Results Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9. Conclusions and Relevance In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
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Affiliation(s)
- Eirini Karyotaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Department of Psychiatry, University of Oxford, Oxford, England
| | - Clara Miguel
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Toshi A. Furukawa
- Department of Clinical Psychology and Psychotherapy, University of Wuppertal, Wuppertal, Germany
- Department of Health Promotion and Human Behavior, Department of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Pim Cuijpers
- Department of Clinical Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
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Provoost S, Kleiboer A, Ornelas J, Bosse T, Ruwaard J, Rocha A, Cuijpers P, Riper H. Improving adherence to an online intervention for low mood with a virtual coach: study protocol of a pilot randomized controlled trial. Trials 2020; 21:860. [PMID: 33066805 PMCID: PMC7565359 DOI: 10.1186/s13063-020-04777-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 09/29/2020] [Indexed: 01/17/2023] Open
Abstract
Background Internet-based cognitive-behavioral therapy (iCBT) is more effective when it is guided by human support than when it is unguided. This may be attributable to higher adherence rates that result from a positive effect of the accompanying support on motivation and on engagement with the intervention. This protocol presents the design of a pilot randomized controlled trial that aims to start bridging the gap between guided and unguided interventions. It will test an intervention that includes automated support delivered by an embodied conversational agent (ECA) in the form of a virtual coach. Methods/design The study will employ a pilot two-armed randomized controlled trial design. The primary outcomes of the trial will be (1) the effectiveness of iCBT, as supported by a virtual coach, in terms of improved intervention adherence in comparison with unguided iCBT, and (2) the feasibility of a future, larger-scale trial in terms of recruitment, acceptability, and sample size calculation. Secondary aims will be to assess the virtual coach’s effect on motivation, users’ perceptions of the virtual coach, and general feasibility of the intervention as supported by a virtual coach. We will recruit N = 70 participants from the general population who wish to learn how they can improve their mood by using Moodbuster Lite, a 4-week cognitive-behavioral therapy course. Candidates with symptoms of moderate to severe depression will be excluded from study participation. Included participants will be randomized in a 1:1 ratio to either (1) Moodbuster Lite with automated support delivered by a virtual coach or (2) Moodbuster Lite without automated support. Assessments will be taken at baseline and post-study 4 weeks later. Discussion The study will assess the preliminary effectiveness of a virtual coach in improving adherence and will determine the feasibility of a larger-scale RCT. It could represent a significant step in bridging the gap between guided and unguided iCBT interventions. Trial registration Netherlands Trial Register (NTR) NL8110. Registered on 23 October 2019.
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Affiliation(s)
- Simon Provoost
- Department of Clinical, Neuro- and Developmental Psychology, Clinical Psychology Section, VU University and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
| | - Annet Kleiboer
- Department of Clinical, Neuro- and Developmental Psychology, Clinical Psychology Section, VU University and Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - José Ornelas
- Institute for Systems and Computer Engineering, Technology and Science, Porto, Portugal
| | - Tibor Bosse
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
| | - Jeroen Ruwaard
- Department of Psychiatry, Amsterdam UMC, Location VU University Medical Centre, and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.,GGZ inGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Artur Rocha
- Institute for Systems and Computer Engineering, Technology and Science, Porto, Portugal
| | - Pim Cuijpers
- Department of Clinical, Neuro- and Developmental Psychology, Clinical Psychology Section, VU University and Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Heleen Riper
- Department of Clinical, Neuro- and Developmental Psychology, Clinical Psychology Section, VU University and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.,Department of Psychiatry, Amsterdam UMC, Location VU University Medical Centre, and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.,GGZ inGeest Specialized Mental Health Care, Amsterdam, Netherlands
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Stoll J, Müller JA, Trachsel M. Ethical Issues in Online Psychotherapy: A Narrative Review. Front Psychiatry 2020; 10:993. [PMID: 32116819 PMCID: PMC7026245 DOI: 10.3389/fpsyt.2019.00993] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/13/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The provision of psychotherapy over distance using technology is a growing market reaching many patients and therefore the risks and benefits need to be known by all psychotherapists whether they themselves practice online or not. This comprehensive review of the main ethical arguments for and against different forms of online psychotherapy aims to enhance discussion of ethical issues in this growing area. METHODS A search of three databases (PubMed, PsycINFO, Web of Science) was conducted in August 2019 using a specific search protocol yielding 249 publications. RESULTS Of 24 ethical arguments in favor of online psychotherapy and 32 against, the top five ethical arguments in favor of online psychotherapy were (1) increased access to psychotherapy and service availability and flexibility; (2) therapy benefits and enhanced communication; (3) advantages related to specific client characteristics (e.g. remote location); (4) convenience, satisfaction, acceptance, and increased demand; and (5) economic advantages. The top five ethical arguments against engagement in online psychotherapy were (1) privacy, confidentiality, and security issues; (2) therapist competence and need for special training; (3) communication issues specific to technology; (4) research gaps; and (5) emergency issues. CONCLUSIONS The findings may be of help to practitioners in deciding whether to engage in online psychotherapy, and in informing patients about risks and benefits, improving ethical guidelines, and stimulating further ethical discussion. The findings are argumentative and qualitative in nature, and further quantitative research is needed.
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Affiliation(s)
| | | | - Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
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