Mathematical Model of Interaction of Therapist and Patients with Bipolar Disorder: A Systematic Literature Review

Mood swings in patients with bipolar disorder (BD) are difficult to control and can lead to self-harm and suicide. The interaction between the therapist and BD will determine the success of therapy. The interaction model between the therapist and BD begins by reviewing the models that were previously developed using the Systematic Literature Review and Bibliometric methods. The limit of articles used was sourced from the Science Direct, Google Scholar, and Dimensions databases from 2009 to 2022. The results obtained were 67 articles out of a total of 382 articles, which were then re-selected. The results of the selection of the last articles reviewed were 52 articles. Using VOSviewer version 1.6.16, a visualization of the relationship between the quotes “model”, “therapy”, “emotions”, and “bipolar disorder” can be seen. This study also discusses the types of therapy that can be used by BD, as well as treatment innovations and the mathematical model of the therapy itself. The results of this study are expected to help further researchers to develop an interaction model between therapists and BD to improve the quality of life of BD.

Feasibility of Text Messages for Enhancing Therapeutic Engagement Among Youth and Caregivers Initiating Outpatient Mental Health Treatment: Mixed Methods Study

BACKGROUND

Pathways to mental health services for youth are generally complex and often involve numerous contact points and lengthy delays. When starting treatment, there are a host of barriers that contribute to low rates of therapeutic engagement. Automated text messages offer a convenient, low-cost option for information sharing and skill building, and they can potentially activate positive behaviors in youth and caregivers prior to beginning formal therapy. To date, there is little evidence for the feasibility of initiating transdiagnostic text messages during the early stages of youth and caregiver contact with community outpatient mental health services.

OBJECTIVE

To develop and test the feasibility of implementing 2 novel text messaging campaigns aimed at youth clients and their caregivers during the early stages of engaging with outpatient mental health services.

METHODS

A multidisciplinary panel of experts developed two 12-message interventions with youth and caregivers prior to deployment. Each message included a link to an external interactive or multimedia resource to extend skill development. Enrollment of youth aged 13 to 18 years, their caregivers, or both occurred at 2 early treatment timepoints. At both time points, text messages were delivered automatically 2 times a week for 6 weeks. Analytics and survey data were collected in 2 phases, between January and March 2020 and between January and May 2021. Enrollment, willingness to persist in using the intervention, engagement, satisfaction, perceived value, and impact were measured. Descriptive statistics were used to summarize youth and caregiver outcomes.

RESULTS

A total of 41 caregivers and 36 youth consented to participate. Follow-up survey response rates were 54% (22/41) and 44%, (16/36) respectively. Over 1500 text messages were sent throughout the study. More than three-quarters (14/16, 88%) of youth reported that they learned something new and noticed a change in themselves due to receiving the texts; the same proportion (14/16, 88%) of youth said they would recommend the text messages to others. Youth ranked the first text message, related to coping with difficult emotions, as the most helpful of the series. Caregivers reported acting differently due to receiving the texts. Over two-thirds of caregivers were satisfied with the texts (16/22, 73%) and would recommend them to others (16/22, 73%). Caregivers perceived diverse levels of value in the text topics, with 9 of the 12 caregiver texts rated by at least one caregiver as the most helpful.

CONCLUSIONS

Results are preliminary but show that brief, core skill-focused text messages for youth clients and caregivers in community outpatient mental health services are feasible. Both youth and caregivers reported promising knowledge and behavior change with exposure to only 12 messages over 6 weeks. A larger study with statistical power to detect changes in both perceived helpfulness and engagement is required to confirm the effectiveness of this type of transdiagnostic intervention.

An Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Prolonged Grief Disorder (PGD) in adults: A multiple-baseline single-case experimental design study

The death of a loved one has physical, psychological, and social consequences. Between 9.8 and 21.5 % of people who lose a loved one develop Prolonged Grief Disorder (PGD). Internet- and computer-based interventions (i.e., Internet-delivered Cognitive-Behavioral Therapy, iCBT) are cost-effective and scalable alternatives that make it possible to reach more people with PGD. The main goal of the present investigation was to examine the effect and feasibility (usability and satisfaction) of an iCBT (GROw program) for adults with PGD. A secondary objective was to detect adherence to the app (Emotional Monitor) used to measure daily grief symptoms. The study had a single-case multiple-baseline AB design with six participants. The GROw program is organized sequentially in eight modules, and it is based on the dual-process model of coping with bereavement. Evaluations included a pre-to-post treatment assessment of depression, grief symptoms, and typical grief beliefs, along with daily measures of symptom frequency and intensity on the Emotional Monitor App. Treatment opinions and adherence to the App were also collected. Efficacy data were calculated using a Nonoverlap of All Pairs (NAP) analysis and Reliable Change Index (RCI). The mean age of the sample was 29.5 years (SD = 8.19). Two participants dropped out of the study. Adherence to the App varied across patients (4.8 % -77.8 %). Most participants (75 %) showed a clinically significant change (recovered) in depression, and 50 % obtained a clinically significant improvement (recovered) in symptoms of loss and typical beliefs in complicated grief. The participants reported high usability and satisfaction with the treatment content and format. In sum, the GROw program was very well accepted and generally feasible, and it has strong potential for treating PGD. The results support scaling up the treatment by using more complex designs with larger samples (i.e., randomized controlled trials comparing GROw with active conditions).

Commentary: Are complex parenting interventions less than the sum of their parts? A reflection on Leijten et al. (2022)

Parenting interventions provide the backbone of professional support for children with behavioural problems and their families (Maughan et al., 2005). The overwhelming evidence for their value, at least in the short term, has prompted the field to move away from simply testing their efficacy to focus on issues of implementation. More and more studies are therefore addressing the interrelated goals of optimising outcomes, increasing scalability and affordability, improving access and removing barriers for hard-to-reach and treat families (e.g., Barnett et al., 2019; Day et al., 2012; Kazdin, 2015). Because parenting interventions are often complex and integrate multiple discrete therapeutic elements, achieving cost-effective interventions that can be implemented efficiently at scale will depend on identifying which elements work best and which are redundant and can be cut. This can help streamline interventions to make them less burdensome by cutting the time, effort and resources needed for families to take part and making the interventions themselves easier to train and deliver. It can also help focus energies on areas where improvements of existing interventions are most needed and/or likely to yield the most value. Leijten and colleagues (2022) addressed these issues in their excellent review.

Internet-delivered Cognitive-Behavioral Therapy (iCBT) for Adults with Prolonged Grief Disorder (PGD): A Study Protocol for a Randomized Feasibility Trial

INTRODUCTION

Grief is an emotional reaction to the loss of a loved one with a natural recovery. Approximately 10% of people who lose a loved one develop prolonged grief disorder (PGD). Internet-based and computer-based interventions (ie, internet-delivered cognitive-behavioural therapy, iCBT) are a cost-effective alternative that makes it possible to reach more people with PGD. The main aim of this study is to assess the feasibility of a new iCBT-called GROw-for PGD. As a secondary objective, the potential effectiveness of GROw will be explored.

METHODS AND ANALYSIS

This study is a two-arm feasibility randomised trial. A total of 48 adults with PGD who meet the eligibility criteria will be randomised to the experimental group (iCBT: GROw) or the active control group (face-to-face CBT treatment). The treatment is organised sequentially in eight modules in the iCBT format and 8-10 sessions in the face-to-face format, and both formats have the same therapeutic components. There will be five assessment points with qualitative and quantitative evaluations: screening, baseline, after the intervention, 3-month follow-up and 12-month follow-up. Consistent with the objectives, the measures are related to the feasibility outcomes for the main aim of the study (participant adherence, expectations and satisfaction with the treatment, preferences, alliance and utility) and psychological and mental health outcomes for secondary analyses (symptoms of grief, symptoms of depression, symptoms of anxiety, affectivity, quality of life, work and social adaptation, post-traumatic growth, purpose in life, mindfulness and compassion).

ETHICS AND DISSEMINATION

The Ethics Committee of the Universitat Jaume I (Castellón, Spain) granted approval for the study (CD/002/2019). Dissemination will include publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04462146.

Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment

In-person psychotherapy (IPP) has a long and storied past, but technology advances have ushered in a new era of video-delivered psychotherapy (VDP). In this meta-analysis, pre-post changes within VDP were evaluated as were outcome differences between VDP versus IPP or other comparison groups. A literature search identified k = 56 within-group studies (N = 1681 participants) and 47 between-group studies (N = 3564). The pre-post effect size of VDP was large and highly significant, g = +0.99 95% CI [0.67-0.31]. VDP was significantly better in outcome than wait list controls (g = 0.77) but negligible in difference from IPP. Within-groups heterogeneity of effect sizes was reduced after subgrouping studies by treatment target, of which anxiety, depression, and posttraumatic stress disorder (PTSD) (each with k > 5) had effect sizes nearing 1.00. Disaggregating within-groups studies by therapy type, the effect size was 1.34 for CBT and 0.66 for non-CBT. Adjusted for possible publication bias, the overall effect size of VDP within groups was g = 0.54. In conclusion, substantial and significant improvement occurs from pre- to post-phases of VDP, this in turn differing negligibly from IPP treatment outcome. The VDP improvement is most pronounced when CBT is used, and when anxiety, depression, or PTSD are targeted, and it remains strong though attenuated by publication bias. Clinically, therapy is no less efficacious when delivered via videoconferencing than in-person, with efficacy being most pronounced in CBT for affective disorders. Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta-analytic evidence.

Transdiagnostic Internet-delivered cognitive behaviour therapy with therapist support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists (n = 233); 2) once-weekly support also offered by specialized therapists (n = 216); or 3) once-weekly support offered by community clinic therapists (n = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients (M: 13 versus 9) and required more therapist time over treatment (M: 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care.

Right care, first time: a highly personalised and measurement-based care model to manage youth mental health

Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.

Standalone DBT Group Skills Training Versus Standard (i.e. All Modes) DBT for Borderline Personality Disorder: A Natural Quasi-experiment in Routine Clinical Practice

We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.

Can Between-Session Homework Be Delivered Digitally? A Pilot Randomized Clinical Trial of CBT for Adjustment Disorders

Adjustment disorder (AjD) is one of the most common disorders in clinical practice, and its symptoms are severe enough to cause great distress and functional impairment. The AjD CBT protocol specifically developed for this disorder has shown positive results when delivered face to face and through virtual reality. Despite existing evidence supporting the benefits of therapeutic homework as part of a psychological intervention, little is known about how to increase homework engagement in psychotherapy. This study examines the feasibility (doability, initial efficacy and acceptability) of a digital support system to deliver homework via the Internet in the treatment of AjD. Participants were randomly assigned to a traditional homework condition or a digital support system condition. Both interventions resulted in statistically significant improvements, with large effect sizes, in all the outcome measures at post-treatment, with no significant differences between groups. At 12-month follow-up, these therapeutic gains were maintained, and an improvement was even observed in both conditions, with no significant differences between groups. Additionally, treatment satisfaction predicted efficacy in both groups separately and when the whole group was considered. This is the first study to explore the feasibility an initial efficacy of delivering a therapeutic homework component for AjD through the Internet.

Transdiagnostic, internet-delivered cognitive behavior therapy for depression and anxiety: Exploring impact on health anxiety

Health anxiety is associated with significant personal distress and economic cost; as such, widely available and effective treatment options are crucial. Several studies suggest that Internet-delivered cognitive behavior therapy (ICBT) programs that specifically target health anxiety are efficacious for this condition. However, no known studies have examined the impact of transdiagnostic ICBT, which emphasizes the acquisition of broad coping skills applicable to a variety of mental health concerns, on symptoms of health anxiety. The current study sought to explore changes in health anxiety symptoms by utilizing data available from a previously published study of 8-week transdiagnostic ICBT. Specifically, changes in symptoms of health anxiety in response to a transdiagnostic ICBT program that targeted broad symptoms of depression and anxiety, were examined in a subsample of individuals who endorsed elevated symptom scores on the Short Health Anxiety Inventory at pre-treatment (n = 72). Following treatment, large reductions in health anxiety symptoms (Cohen's d = 0.91; 20% improvement), depression (Cohen's d = 0.85; reduction = 38%), generalized anxiety (Cohen's d = 1.21; reduction = 42%), and disability (Cohen's d = 0.90; reduction = 35%) were reported. Furthermore, results showed that transdiagnostic ICBT was rated as acceptable to people with high health anxiety symptoms. Despite elevated pre-treatment health anxiety scores, email correspondence between clients and their therapist revealed very few mentions of health anxiety. These findings provide preliminary evidence for transdiagnostic ICBT for symptoms of health anxiety and suggest further research is warranted.

Effectiveness, acceptability and feasibility of an Internet-delivered cognitive behavioral pain management program in a routine online therapy clinic in Canada

Background

Access to face-to-face cognitive behavioral pain management programs is very limited. Internet-delivered cognitive behavioral pain management has potential to improve client access to care but is not readily available in Canada.

Aims

The present study explored the effectiveness, acceptability, and feasibility of a previously validated Internet-delivered cognitive behavioral pain management course, the Pain Course, when offered in a publicly funded provincial Online Therapy Clinic. The five-lesson course was delivered over 8 weeks and was accompanied by brief weekly contact from a coach via weekly telephone calls and secure online messages.

Methods

A single-group open trial design (ISRCTN15509834) was employed (n = 55). Effectiveness was assessed by examining symptom measures at pretreatment, posttreatment, and 3-month follow-up. Completion rates and satisfaction ratings were used to examine acceptability. Feasibility was assessed by examining time required for service delivery.

Results

Results were highly comparable to past studies of the Pain Course showing improvements on primary measures of disability (Cohen’s d = 0.45; 18% reduction), depression (Cohen’s d = 0.85; 36% reduction), and anxiety (Cohen’s d = 0.52; 32% reduction) at posttreatment that were maintained at follow-up. Completion rates (76%) and course satisfaction ratings (85% would recommend course) were high. Coach time per week was estimated as M = 12.67 (SD = 6.53) min.

Conclusions

The findings add to existing literature on the Pain Course demonstrating for the first time the effectiveness, acceptability, and feasibility of Internet-delivered cognitive behavioral pain management programs for adults with chronic pain in a routine online therapy clinic.

Who benefits most from therapist-assisted internet-delivered cognitive behaviour therapy in clinical practice? Predictors of symptom change and dropout

Internet-delivered cognitive behavioral therapy (ICBT) is effective for treating anxiety and depression, but not for all patients. Predictors of dropout and outcomes from ICBT remain unclear and the literature could benefit from study of response to ICBT among larger community samples using advanced statistical techniques. In this study, we sought to identify predictors of dropout and symptom change in a large community sample (n = 1201) who received therapist-assisted transdiagnostic ICBT targeting anxiety and/or depression. Logistic regression was used to assess dropout, and showed that those who fully completed ICBT lessons (n = 880) were older and endorsed lower psychological distress at intake than those who only partially completed ICBT lessons (n = 321). During the course of therapy, patients responded to the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 at six time points. Autoregressive latent trajectory models were fitted to this data to assess the ability of demographic variables, program engagement, psychological and medical service usage, and psychological distress to explain individual variance in initial symptom levels and symptom change over time. Higher symptom scores at pre-treatment were predictive of greater symptom improvement. Symptom improvement was greater in those who were off work on disability and those without higher post-secondary education. Clinical implications are discussed.

The first 30 months of the MindSpot Clinic: Evaluation of a national e-mental health service against project objectives

OBJECTIVE

The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services, improving public awareness of how to access services and providing evidence-based treatments.

METHOD

Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilisation and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also analysed. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale-Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist-Civilian Version, administered at assessment, post-treatment and 3-month follow-up.

RESULTS

The website was visited by almost 500,000 Australians, of which 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. Mean age was 36.4 years (standard deviation = 13.3 years; range = 18-94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects ( d: 0.7-2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%.

CONCLUSION

Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three programme objectives. This model of service provision has considerable value as a complement to existing services, and is proving particularly important for improving access for people not using existing services.

Systematic review of the evidence base for treatment of common mental disorders in South Africa

The scarcity of mental health resources in low- and middle-income countries requires the identification of effective interventions that can be taken to scale in a cost-efficient manner. Yet the evidence base for treatment of common mental disorders in low- and middle-income countries remains limited. As one of the better resourced countries on the African continent, South Africa could potentially play a leading role in developing an African evidence base for mental health care. This study sought to describe and evaluate the South African evidence base for treating common mental disorders. A systematic review of randomised controlled trials for depression, substance use, and anxiety in the adult South African population from 2000 to mid-2015 was conducted. Eligible studies were assessed for their consistency with recommendations for mental health interventions in low- and middle-income countries and for methodological and reporting rigour. A total of 16 RCTs satisfied the inclusion criteria, of which 8 targeted depression, 6 targeted substance use, and 2 targeted anxiety symptoms. There has been a strong trend towards alignment with prevailing recommendations for delivery of mental health interventions in resource-scarce regions. While there are some promising findings with regard to effectiveness of specific interventions, replication, costing, and dissemination studies are still required and there is still an urgent need for treatment studies for anxiety disorders, which are the most common class of common mental disorder in South Africa. The review also indicates that research design and reporting practices in South African mental health intervention research could be enhanced and recommendations towards this are suggested.

Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial

Fibromyalgia (FM) is a common and often debilitating chronic pain condition. Research shows that symptoms of depression and anxiety are present in up to three quarters of individuals with FM. Of concern, most adults with FM cannot access traditional face-to-face cognitive behavioural pain management programs, which are known to be beneficial. Given known difficulties with treatment access, the present study sought to explore the efficacy and acceptability of a previously developed Internet-delivered cognitive behavioural pain management course, the Pain Course, for adults with FM. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email, with a guide throughout the course. Participants were randomized either to the Pain Course (n = 30) or to a waiting-list control group (n = 30). Symptoms were assessed at pre-treatment, post-treatment and 4-week follow-up. Completion rates (87%) and satisfaction ratings (86%) were high. Improvements were significantly greater in treatment group participants compared to waiting-list group participants on measures of FM (Cohen's d =.70; 18% reduction), depression (Cohen's d =.63-.72; 20-28% reduction), pain (Cohen's d =.87; 11% improvement) and fear of pain (Cohen's d =1.61; 12% improvement). Smaller effects were also observed on measures of generalized anxiety and physical health. The changes were maintained at four-week follow-up. The current findings add to existing literature and highlight the specific potential of Internet-delivered cognitive behavioural pain management programs for adults with FM, especially as a part of stepped-care models of care. Future research directions are described.

Mental healthcare providers’ attitudes towards the adoption of evidence-based practice in the treatment of post-traumatic stress disorder in South Africa

South African society is characterised by a high prevalence of exposure to traumatic events that can lead to post-traumatic stress disorder. In treating post-traumatic stress disorder, mental healthcare providers are tasked with ensuring that their practice is evidence based. However, existing evidence indicates that the rates of adoption of evidence-based practice are generally poor. The promotion and implementation of evidence-based practice into routine clinical settings requires an understanding of the attitudes of mental healthcare providers towards these practices. This study investigated attitudes towards evidence-based practice in the treatment of post-traumatic stress disorder. Participants were 60 mental healthcare providers (clinical/counselling psychologists, social workers, and registered counsellors) in the Western Cape Province working predominantly with trauma survivors. Participants completed a demographic survey and the Attitude Towards Evidence-Based Practice Scale, adapted to assess for attitudes towards the adoption of evidence-based practice in relation to the treatment of post-traumatic stress disorder. Overall, participants reported favourable attitudes towards evidence-based practice in the treatment of post-traumatic stress disorder. Statistical analysis revealed that occupation, age, and gender significantly correlated with attitudes. Social workers and registered counsellors were more likely to report adopting evidence-based practice for post-traumatic stress disorder compared to clinical and counselling psychologists. Older participants and women also reported more favourable attitudes towards evidence-based practice. The implications of these findings are discussed.

An Internet-based treatment for flying phobia (NO-FEAR Airlines): study protocol for a randomized controlled trial

BACKGROUND

Flying phobia (FP) is a common and disabling mental disorder. Although in vivo exposure is the treatment of choice, it is linked to a number of limitations in its implementation. Particularly important, is the limited access to the feared stimulus (i.e., plane). Moreover, the economic cost of in vivo exposure should be specially considered as well as the difficulty of applying the exposure technique in an appropriate way; controlling important variables such as the duration of the exposure or the number of sessions. ICTs could help to reduce these limitations. Computer-assisted treatments have remarkable advantages in treating FP. Furthermore, they can be delivered through the Internet, increasing their advantages and reaching more people in need. The Internet has been established as an effective way to treat a wide range of mental disorders. However, as far as we know, no controlled studies exist on FP treatment via the Internet. This study aims to evaluate the efficacy of an Internet-based treatment for FP (NO-FEAR Airlines) versus a waiting list control group. Secondary objectives will be to explore two ways of delivering NO-FEAR Airlines, with or without therapist guidance, and study the patients' acceptance of the program. This paper presents the study protocol.

METHODS/DESIGN

The study is a randomized controlled trial. A minimum of 57 participants will be randomly assigned to three conditions: a) NO-FEAR Airlines totally self-applied, b) NO-FEAR Airlines with therapist guidance, or c) a waiting list control group (6 weeks). Primary outcomes measures will be the Fear of Flying Questionnaire-II and the Fear of Flying Scale. Secondary outcomes will be included to assess other relevant clinical measures, such as the Fear and Avoidance Scales, Clinician Severity Scale, and Patient's Improvement scale. Analyses of post-treatment flights will be conducted. Treatment acceptance and preference measures will also be included. Intention-to-treat and per protocol analyses will be conducted.

DISCUSSION

An Internet-based treatment for FP could have considerable advantages in managing in vivo exposure limitations, specifically in terms of access to treatment, acceptance, adherence, and the cost-effectiveness of the intervention. This is the first randomized controlled trial to study this issue.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02298478 . Trial registration date 3 November 2014.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for Social Anxiety Disorder and comorbid disorders: A randomized controlled trial

Disorder-specific (DS-CBT) and transdiagnostic (TD-CBT) cognitive behaviour therapy have both been used to treat social anxiety disorder (SAD). This study compared internet-delivered DS-CBT and TD-CBT for SAD across clinician-guided (CG-CBT) and self-guided (SG-CBT) formats. Participants with SAD (n=233) were randomly allocated to receive internet-delivered TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of SAD (Cohen's d≥1.01; avg. reduction≥30%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d≥1.25; avg. reduction≥39%), generalised anxiety disorder (Cohen's d≥0.86; avg. reduction≥36%) and panic disorder (Cohen's d≥0.53; avg. reduction≥25%) were found immediately post-treatment and were maintained or further improved to 24-month follow-up. No marked differences were observed between TD-CBT and DS-CBT or CG-CBT and SG-CBT highlighting the potential of each for the treatment of SAD and comorbid disorders.

Transdiagnostic Internet-delivered cognitive behaviour therapy in Canada: An open trial comparing results of a specialized online clinic and nonspecialized community clinics

Effects of Internet-delivered cognitive behaviour therapy (ICBT) for anxiety and depression are not well understood when delivered in non-specialized as compared to specialized clinic settings. This open trial (n=458 patients) examined the benefits of transdiagnostic-ICBT when delivered in Canada by therapists (registered providers or graduate students) working in either a specialized online clinic or one of eight nonspecialized community clinics. Symptoms of depression and anxiety were assessed at pre-treatment, post-treatment and at 3-month follow-up. Completion rates and satisfaction were high. Significant and large reductions (effect sizes 1.17-1.31) were found on symptom measures. Completion rates, satisfaction levels and outcomes did not differ whether ICBT was delivered by therapists working in a specialized online clinic or nonspecialized community clinics. Differences were also not found between registered providers and graduate students, or therapists trained in psychology or another discipline. The findings support the public health potential of ICBT.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: A randomized controlled trial

Transdiagnostic cognitive behaviour therapy (TD-CBT) aims to target the symptoms of multiple disorders whereas disorder-specific CBT (DS-CBT) targets the symptoms of principal disorders. This study compared the relative benefits of internet-delivered TD-CBT and DS-CBT when provided in clinician-guided (CG-CBT) and self-guided (SG-CBT) formats for people with a principal diagnosis of Panic Disorder (PD). Participants (n=145) were randomly allocated to receive TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of PD (Cohen's d ≥ 0.71; avg. reduction ≥ 36%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d ≥ 0.71; avg. reduction ≥ 33%), generalised anxiety disorder (Cohen's d ≥ 0.91; avg. reduction ≥ 34%) and social anxiety disorder (Cohen's d ≥ 0.50; avg. reduction ≥ 15%) were found over the 24-month follow-up period. Highlighting their efficacy and acceptability, no marked and consistent differences were observed between TD-CBT and DS-CBT or CG-CBT and DS-CBT.

International education and training for clinical child and adolescent psychology

Psychological problems in youth and adequate mental health service delivery to children, adolescents, and families are critical public health dilemmas around the world. Central to effectively addressing the mental health needs of youth and families is focusing attention on the evaluation and development of specialized training programs in clinical child and adolescent psychology. All countries to more or less degree face challenges, but lower-income countries have additional limitations (e.g., scarce resources for training, high demand for services, cultural barriers) to establishing clinical psychology programs and specialized services for children and adolescents. This article discusses the status of efforts in the United States to define clinical child and adolescent psychology and develop standard training recommendations for mental health providers who work with youth and families, international considerations for intervention implementation and training, and future directions in the field of clinical child and adolescent psychology.

Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for generalized anxiety disorder and comorbid disorders: A randomized controlled trial

Generalized anxiety disorder (GAD) can be treated effectively with either disorder-specific cognitive behavior therapy (DS-CBT) or transdiagnostic CBT (TD-CBT). The relative benefits of DS-CBT and TD-CBT for GAD and the relative benefits of delivering treatment in clinician guided (CG-CBT) and self-guided (SG-CBT) formats have not been examined. Participants with GAD (n=338) were randomly allocated to receive an internet-delivered TD-CBT or DS-CBT intervention delivered in either CG-CBT or SG-CBT formats. Large reductions in symptoms of GAD (Cohen's d ≥ 1.48; avg. reduction ≥ 50%) and comorbid major depressive disorder (Cohen's d ≥ 1.64; avg. reduction ≥ 45%), social anxiety disorder (Cohen's d ≥ 0.80; avg. reduction ≥ 29%) and panic disorder (Cohen's d ≥ 0.55; avg. reduction ≥ 33%) were found across the conditions. No substantive differences were observed between DS-CBT and TD-CBT or CG-CBT and SG-CBT, highlighting the public health potential of carefully developed TD-CBT and SG-CBT.

Gender moderates the relationship between attachment insecurities and emotion dysregulation

The relation between attachment styles and emotion regulation is well documented, and emotion dysregulation is considered characteristic of individuals with insecure attachment styles. Although gender differences in emotion regulation have often been reported, it is not clear whether the association between attachment styles and aspects of emotion dysregulation may vary across gender. A sample of 229 newlywed couples completed the Experiences in Close Relationship–Revised scale and the Difficulties in Emotion Regulation Scale. First, we confirmed previous evidence on the association between attachment insecurities and emotion dysregulation. Indeed, attachment anxiety and avoidance were both related to emotional nonacceptance and lack of emotional clarity. Moreover, attachment anxiety was associated with difficulties in impulse control and limited access to effective emotion regulation strategies, whereas attachment avoidance was uniquely related to lack of emotional awareness. Finally, gender was found to moderate the association that both attachment anxiety and attachment avoidance had with difficulties in pursuing desired goals when experiencing negative emotions. Specifically, among women (but not men), attachment anxiety was associated with greater difficulties in engaging in goal-directed behavior when distressed. Conversely, the association between attachment avoidance and difficulties in pursuing desired goals when distressed was positive for men and negative for women.

Clinical dysfunction and psychosocial interventions: the interplay of research, methods, and conceptualization of challenges

I describe the development and course of my research in studying clinical dysfunction among children, adolescents, and adults. This is an autobiographical account that highlights programs of research, career moves, and experiences along the way that were particularly influential. Research on specific topics and the methods to study them were inherently fascinating but invariably led me to broader issues well beyond what I was studying. The research alerted me to how and why current methods, assumptions, and research practices might be constraining and perhaps slightly misguided. My research and specific findings in a given area were not necessarily part of any particular breakthrough but rather helped me see how more, different, and better work was needed. Collaborations with a diverse set of colleagues and models from other disciplines than psychology helped me conceptualize the goals of research on a given topic (e.g., developing evidence-based treatments, reducing the burden of mental illness, promoting a sustainable environment to mitigate climate change) and propose a shift from current practices as a means to obtain them.