Rationale and design of a systematic review: effectiveness and acceptance of technology-based psychological interventions in different clinical phases of depression management

Design and Preliminary Realization of a Screening and Early Warning Health Management System for Populations at High Risk for Depression

Depression has a high incidence in the world. Based on the concept of preventive treatment of disease of traditional Chinese medicine, timely screening and early warning of depression in populations at high risk for this condition can avoid, to a certain extent, the dysfunctions caused by depression. This work studied a method to collect information on depression, generate a database of depression features, design algorithms for screening populations at high risk for depression and creating an early warning model, develop an early warning short-message service (SMS) platform, and implement a scheme of depression screening and an early warning health management system. The implementation scheme included mobile application (app), cloud form, screening and early warning model, cloud platform, and computer software. Multiple modules jointly realized the screening, early warning, and management of the health functions of individuals at high risk for depression. At the same time, function modules such as mobile app and cloud form for collecting depression health information, early warning SMS platform, and health management software were designed, and the functions of the modules were preliminarily developed. Finally, the black-box test and white-box test were used to assess the system’s functions and ensure the reliability of the system. Through the integration of mobile app and computer software, this study preliminarily realized the screening and early warning health management of a population at high risk for depression.

[Technology-Based Psychological Interventions (TBIs) for Bridging Waiting Periods and Aftercare for People with Depressive Disorders: The Current State of Research]

Our goal was to present current research on the effectiveness, acceptance and safety of technology-based psychological interventions (TBIs) for bridging waiting periods (e. g., for outpatient psychotherapy) and aftercare of people with depressive disorders and to derive implications for future research. In this systematic review of 83 studies, the use of TBIs in people with diagnosed depression was analyzed. Among these, only a few studies were identified as those applying TBIs for bridging waiting periods (n=1) and aftercare (n=4). The narrative summary of results suggests the effectiveness of TBIs for aftercare. However, very few data are available on TBIs regarding their acceptance, safety and use for bridging waiting periods. The current evidence base is insufficient for recommending the use of TBIs for bridging waiting periods and for aftercare. Further randomized controlled trials capturing effectiveness, acceptance, safety, and the potential for implementation of TBIs under real-world care conditions are needed.

Evidence on Technology-Based Psychological Interventions in Diagnosed Depression: Systematic Review

BACKGROUND

Evidence on technology-based psychological interventions (TBIs) for the treatment of depression is rapidly growing and covers a broad scope of research. Despite extensive research in this field, guideline recommendations are still limited to the general effectiveness of TBIs.

OBJECTIVE

This study aims to structure evidence on TBIs by considering different application areas (eg, TBIs for acute treatment and their implementation in health care, such as stand-alone interventions) and treatment characteristics (eg, therapeutic rationale of TBIs) to provide a comprehensive evidence base and to identify research gaps in TBIs for diagnosed depression. Moreover, the reporting of negative events in the included studies is investigated in this review to enable subsequent safety assessment of the TBIs.

METHODS

Randomized controlled trials on adults diagnosed with unipolar depression receiving any kind of psychotherapeutic treatment, which was at least partly delivered by a technical medium, were eligible for inclusion in our preregistered systematic review. We searched for trials in CENTRAL (Cochrane Central Register of Controlled Trials; until August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL; until the end of January 2018), clinical trial registers, and sources of gray literature (until the end of January 2019). Study selection and data extraction were conducted by 2 review authors independently.

RESULTS

Database searches resulted in 15,546 records, of which 241 publications were included, representing 83 completed studies and 60 studies awaiting classification (ie, preregistered studies, study protocols). Almost all completed studies (78/83, 94%) addressed the acute treatment phase, being largely either implemented as stand-alone interventions (66/83, 80%) or blended treatment approaches (12/83, 14%). Studies on TBIs for aftercare (4/83, 5%) and for bridging waiting periods (1/83, 1%) were scarce. Most TBI study arms (n=107) were guided (59/107, 55.1%), delivered via the internet (80/107, 74.8%), and based on cognitive behavioral treatment approaches (88/107, 79.4%). Almost all studies (77/83, 93%) reported information on negative events, considering dropouts from treatment as a negative event. However, reports on negative events were heterogeneous and largely unsystematic.

CONCLUSIONS

Research has given little attention to studies evaluating TBIs for aftercare and for bridging waiting periods in people with depression, even though TBIs are seen as highly promising in these application areas; thus, high quality studies are urgently needed. In addition, the variety of therapeutic rationales on TBIs has barely been represented by identified studies hindering the consideration of patient preferences when planning treatment. Finally, future studies should use specific guidelines to systematically assess and report negative events.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-028042.

Effectiveness and acceptance of technology-based psychological interventions for the acute treatment of unipolar depression: a systematic review and meta-analysis (Preprint)

Background

Evidence on technology-based psychological interventions (TBIs) for the acute treatment of depression is rapidly growing. Despite extensive research in this field, there is a lack of research determining effectiveness and acceptance of TBIs considering different application formats in people with a formally diagnosed depressive disorder.

Objective

The goal of the review was to investigate the effectiveness and acceptance of TBIs in people with diagnosed depression with particular focus on application formats (stand-alone interventions, blended treatments, collaborative and/or stepped care interventions).

Methods

Studies investigating adults with diagnosed unipolar depressive disorders receiving any kind of psychotherapeutic treatment delivered (at least partly) by a technical medium and conducted as randomized controlled trials (RCTs) were eligible for inclusion. We searched CENTRAL (Cochrane Central Register of Controlled Trials; August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL (January 2018), clinical trial registers, and sources of grey literature (January 2019). Two independent authors decided about study inclusion and extracted data. We performed random effects meta-analyses to synthesize the data.

Results

Database searches resulted in 15,546 records of which 78 completed studies were included. TBIs delivered as stand-alone interventions showed positive effects on posttreatment depression severity when compared to treatment as usual (SMD –0.44, 95% CI –0.73 to –0.15, k=10; I²=86%), attention placebo (SMD –0.51, 95% CI –0.73 to –0.30; k=12; I²=66%), and waitlist controls (SMD –1.01, 95% CI –1.23 to –0.79; k=19; I²=73%). Superior long-term effects on depression severity were shown when TBIs were compared to treatment as usual (SMD –0.24, 95% CI –0.41 to –0.07; k=6; I²=48%) attention placebo (SMD –0.23, 95% CI –0.40 to –0.07; k=7; I²=21%) and waitlist controls (SMD –0.74, 95% CI –1.31 to –0.18; k=3; I²=79%). TBIs delivered as blended treatments (providing a TBI as an add-on to face-to-face treatment) yielded beneficial effects on posttreatment depression severity (SMD –0.27, 95% CI –0.48 to –0.05; k=8; I²=53%) compared to face-to-face treatments only. Additionally, TBIs delivered within collaborative care trials were more effective in reducing posttreatment (SMD –0.20, 95% CI –0.36 to –0.04; k=2; I²=0%) and long-term (SMD –0.23, 95% CI –0.39 to –0.07; k=2; I²=0%) depression severity than usual care. Dropout rates did not differ between the intervention and control groups in any comparison (all P≥.09).

Conclusions

We found that TBIs are effective not only when delivered as stand-alone interventions but also when they are delivered as blended treatments or in collaborative care trials for people with diagnosed depression. Our results may be useful to inform routine care, since we focused specifically on different application formats, formally diagnosed patients, and the long-term effectiveness of TBIs.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028042

Therapeutic Alliance in Technology-Based Interventions for the Treatment of Depression: Systematic Review

Background

There is growing evidence that technology-based interventions (TBIs) are effective for the treatment of depression. As TBIs are gaining acceptance, a question arises whether good therapeutic alliance, considered a key aspect of psychotherapy, can be established without or with minimal face-to-face contact or rather changes if blended concepts are applied. While therapeutic alliance has been studied extensively in the context of face-to-face therapy, only few studies have reviewed evidence on alliance ratings in TBIs.

Objective

The purpose of this study was to examine therapeutic alliance in technology-based psychological interventions for the treatment of depression.

Methods

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PSYNDEX, CINAHL, clinical trial registers, and sources of grey literature for randomized controlled trials on TBIs in the treatment of adults with unipolar depression. All publications were selected according to prespecified criteria. Data were extracted by two independent reviewers.

Results

A total of eight out of 98 studies (9.5%) included in the review on TBIs for depression considered therapeutic alliance as part of their evaluation. The available data covered eight different treatment conditions, including four stand-alone treatments (face-to-face psychotherapy, email, telephone, and internet program) and four combined treatments (face-to-face psychotherapy plus a smartphone app and an internet program combined with face-to-face psychotherapy, treatment as usual, or email/telephone). On average, patients rated the alliance positively across all groups. Importantly, no relevant group differences regarding therapeutic alliance sum scores were found in any of the studies. Five studies investigated the relationship between patients’ alliance ratings and treatment outcome, revealing mixed results.

Conclusions

Our results suggest that it is possible to establish a positive therapeutic alliance across a variety of different TBIs for depression, but this is based on a small number of studies. Future research needs to determine on what basis therapeutic alliance is formed in settings that do not allow for additional nonverbal cues, perhaps with adapted instruments to measure therapeutic alliance.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413)

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028042