The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression

Digital Psychotherapies for Adults Experiencing Depressive Symptoms: Systematic Review and Meta-Analysis

BACKGROUND

Depression affects 5% of adults and it is a major cause of disability worldwide. Digital psychotherapies offer an accessible solution addressing this issue. This systematic review examines a spectrum of digital psychotherapies for depression, considering both their effectiveness and user perspectives.

OBJECTIVE

This review focuses on identifying (1) the most common types of digital psychotherapies, (2) clients' and practitioners' perspectives on helpful and unhelpful aspects, and (3) the effectiveness of digital psychotherapies for adults with depression.

METHODS

A mixed methods protocol was developed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search strategy used the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework covering 2010 to 2024 and 7 databases were searched. Overall, 13 authors extracted data, and all aspects of the review were checked by >1 reviewer to minimize biases. Quality appraisal was conducted for all studies. The clients' and therapists' perceptions on helpful and unhelpful factors were identified using qualitative narrative synthesis. Meta-analyses of depression outcomes were conducted using the standardized mean difference (calculated as Hedges g) of the postintervention change between digital psychotherapy and control groups.

RESULTS

Of 3303 initial records, 186 records (5.63%; 160 studies) were included in the review. Quantitative studies (131/160, 81.8%) with a randomized controlled trial design (88/160, 55%) were most common. The overall sample size included 70,720 participants (female: n=51,677, 73.07%; male: n=16,779, 23.73%). Digital interventions included "stand-alone" or non-human contact interventions (58/160, 36.2%), "human contact" interventions (11/160, 6.8%), and "blended" including stand-alone and human contact interventions (91/160, 56.8%). What clients and practitioners perceived as helpful in digital interventions included support with motivation and accessibility, explanation of task reminders, resources, and learning skills to manage symptoms. What was perceived as unhelpful included problems with usability and a lack of direction or explanation. A total of 80 studies with 16,072 participants were included in the meta-analysis, revealing a moderate to large effect in favor of digital psychotherapies for depression (Hedges g=-0.61, 95% CI -0.75 to -0.47; Z=-8.58; P<.001). Subgroup analyses of the studies with different intervention delivery formats and session frequency did not have a statistically significant effect on the results (P=.48 and P=.97, respectively). However, blended approaches revealed a large effect size (Hedges g=-0.793), while interventions involving human contact (Hedges g=-0.42) or no human contact (Hedges g=-0.40) had slightly smaller effect sizes.

CONCLUSIONS

Digital interventions for depression were found to be effective regardless of format and frequency. Blended interventions have larger effect size than those involving human contact or no human contact. Digital interventions were helpful especially for diverse ethnic groups and young women. Future research should focus on understanding the sources of heterogeneity based on intervention and population characteristics.

TRIAL REGISTRATION

PROSPERO CRD42021238462; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=238462.

The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss

BACKGROUND

Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss.

METHODS

228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10).

RESULTS

Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms.

CONCLUSION

The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions.

TRIAL REGISTRATION

Not applicable.

[Video-Based Online Metta-Meditation Therapy for Depression: A Pilot Trial Evaluating the Acceptability and Feasibility]

Background

In the course of the Covid-19 pandemic, it has become clear what relevance non-contact psychotherapeutic online interventions in mental health care could possibly have in the future. The present pilot study aims to test whether a Metta-based group program is also an acceptable and feasible treatment when conducted as video-based intervention. Metta meditations aim at showing unconditional benevolence and kindness to oneself and to other people.

Methods

Eight patients with depressive disorder participated in a video-based implementation of the Metta-based group program. Quality of the therapeutic relationship, the implementation of methods as well as the acceptance of the video-based therapy on the part of the participants were surveyed as target variables.

Results

Data indicated good feasibility in terms of a sustainable therapeutic relationship, the possibility of teaching meditation techniques, and the establishment of a concentrated working atmosphere. Videobased therapy met with good acceptance among the participants. Potential indications for its clinical effectiveness are evident.

Conclusion

Teaching Metta meditation in a group program for the treatment of depression can be practicably implemented in a video-based therapy and meets with good acceptance by the patients. Further studies on moderators of acceptance and efficacy of video-based therapy are needed.

Therapeutic Alliance and Group Cohesion Across Telehealth Delivery of Mentalizing-focused Parenting Groups

This study assessed changes in therapeutic alliance and group cohesion among parents/primary caregivers enrolled in Connecting and Reflecting Experience (CARE), a short-term, group-based, mentalizing-focused parenting program designed to support a diverse community facing socioeconomic and health disparities. Caregivers (N = 44) experiencing parenting stress or parent-child relational challenges were recruited from their children's outpatient psychiatry clinic to participate in one of nine 12-session telehealth CARE groups. Caregivers completed the Working Alliance Inventory-Short Revised and the Therapeutic Factors Inventory Cohesiveness subscale after CARE Sessions 1 and 12. Ratings of group cohesion and therapeutic bond with facilitators increased significantly across treatment. Findings indicate that caregivers from underserved families with high levels of parenting stress experienced an increase in group cohesion and therapeutic alliance throughout a telehealth adaptation of CARE.

Web-based guided self-help cognitive behavioral therapy-enhanced versus treatment as usual for binge-eating disorder: a randomized controlled trial protocol

Binge-eating disorder (BED) is a psychiatric disorder characterized by recurrent episodes of eating a large amount of food in a discrete period of time while experiencing a loss of control. Cognitive behavioral therapy-enhanced (CBT-E) is a recommended treatment for binge-eating disorder and is typically offered through 20 sessions. Although binge-eating disorder is highly responsive to CBT-E, the cost of treating these patients is high. Therefore, it is crucial to evaluate the efficacy of low-intensity and low-cost treatments for binge-eating disorder that can be offered as a first line of treatment and be widely disseminated. The proposed noninferiority randomized controlled trial aims to determine the efficacy of web-based guided self-help CBT-E compared to treatment-as-usual CBT-E. Guided self-help will be based on a self-help program to stop binge eating, will be shorter in duration and lower intensity, and will require fewer therapist hours. Patients with binge-eating disorder (N = 180) will be randomly assigned to receive guided self-help or treatment-as-usual. Assessments will take place at baseline, mid-treatment, at the end of treatment, and at 20- and 40-weeks post-treatment. Treatment efficacy will be measured by examining the reduction in binge-eating days in the previous 28 days between baseline and the end of treatment between groups, with a noninferiority margin (Δ) of 1 binge-eating day. Secondary outcomes will include full remission, body shape dissatisfaction, therapeutic alliance, clinical impairment, health-related quality of life, attrition, and an economic evaluation to assess cost-effectiveness and cost-utility. The moderators examined will be baseline scores, demographic variables, and body mass index. It is expected that guided self-help is noninferior in efficacy compared to treatment-as-usual. The proposed study will be the first to directly compare the efficacy and economically evaluate a low-intensity and low-cost binge-eating disorder treatment compared to treatment-as-usual. If guided self-help is noninferior to treatment-as-usual in efficacy, it can be widely disseminated and used as a first line of treatment for patients with binge-eating disorder. The Dutch trial register number is R21.016. The study has been approved by the Medical Research Ethics Committees United on May 25th, 2021, case number NL76368.100.21.

"Own doctor" presence in a web-based lifestyle intervention for adults with obesity and hypertension: A randomized controlled trial

Introduction

Online interventions have long been shown to be an effective means to promote a healthy lifestyle, thereby helping to control body weight and blood pressure figures. Likewise, using video modeling is also considered an effective way to guide patients through behavioral interventions. Nonetheless, to the best of our knowledge, this study is the first to analyze how the presence of patients' "own doctor" in the audiovisual content of a web-based lifestyle program ("Living Better") aimed at promoting regular physical exercise and healthy eating behavior, compared with an "unknown doctor," influences the outcomes of adults with obesity and hypertension.

Materials and methods

A total of 132 patients were randomly assigned either to the experimental (n = 70) or control (n = 62) group ("own doctor" or "unknown doctor", respectively). The body mass index, systolic and diastolic blood pressure, number of antihypertensive drugs used, physical activity level, and quality of life was assessed and compared at baseline and post-intervention (12 weeks).

Results

The intention-to-treat analysis showed intragroup significant improvements in both groups in terms of the body mass index (control group: mean difference -0.3, 95% CI [-0.5, -0.1], p = 0.002; experimental group: -0.4 [-0.6, -0.2], p < 0.001) and systolic blood pressure (control group: -2.3 [-4.4, -0.2], p = 0.029; experimental group: -3.6 [-5.5, -1.6], p< 0.001). In addition, there were also significant improvements in the experimental group for the diastolic blood pressure (-2.5 [-3.7, -1.2], p < 0.001), physical activity (479 [9, 949], p = 0.046), and quality of life (5.2 [2.3, 8.2], p = 0.001). However, when comparing the experimental with the control group, no between-group significant differences were found in these variables.

Conclusions

This study suggests that the presence of patients' "own doctor" in the audiovisual content of a web-based intervention, aimed at promoting a healthy lifestyle among adults with obesity and hypertension, do not show significant additional benefits over the efficacy of e-counseling.

Trial registration

ClinicalTrials.gov NCT04426877. First Posted: 11/06/2020. https://clinicaltrials.gov/ct2/show/NCT04426877.

A short-term manual for webcam-based telemedicine treatment of Internet use disorders

In recent decades, the number of people who experience their Internet use behavior as problematic has risen dramatically. In Germany, a representative study from 2013 estimated the prevalence of Internet use disorder (IUD) to be about 1.0%, with higher rates among younger people. A 2020 meta-analysis shows a global weighted average prevalence of 7.02%. This indicates that developing effective IUD treatment programs is more critical than ever. Studies show that motivational interviewing (MI) techniques are widely used and effective in treating substance abuse and IUDs. In addition, an increasing number of online-based health interventions are being developed to provide a low-threshold treatment option. This article presents a short-term online-based treatment manual for IUDs that combines MI techniques with therapy tools from cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). The manual includes 12 webcam-based therapy sessions, each lasting 50 min. Each session is framed by a standardized beginning, conclusion, outlook, and flexible session content. In addition, the manual contains example sessions to illustrate the therapeutic intervention. Finally, we discuss the advantages and disadvantages of online-based therapy compared to analog treatment settings and provide recommendations for dealing with these challenges. By combining established therapeutic approaches with an online-based therapeutic setting based on flexibility and motivation, we aim to provide a low-threshold solution for treating IUDs.

Cognitive interventions for memory and psychological well-being in aging and dementias

The human lifespan has expanded drastically in the last few centuries, due to improvements in sanitation, medicine, and nutrition, but with this increase in longevity comes higher rates of cognitive pathology such as mild cognitive impairment (MCI) and dementia; the latter is estimated to reach more than 75 million people by 2030. Pathology risk is related to measures of executive function, lifestyle factors (e.g., education, occupation, and leisure activities), and cognitive reserve. One way of building cognitive reserve may be to structure the environment to encourage lifelong engagement and learning, and since a pharmacological "cure" for dementia remains elusive, non-pharmacological approaches such as physical activity, social engagement, and cognitive stimulation are becoming increasingly essential to preserving and protecting brain health. Here, we describe our recent research into Reminiscence Therapy (RT) to promote cognitive and psychological function in old age and early dementia. We review the Recall Initiative, which involved brain imaging and behavioral indices of memory pre- and post-RT. We also report results from a pilot study-AIM WARM-in which RT was combined with physical activity, specifically walking, for early-stage dementia. Finally, we outline our future directions for tailored reminiscence interventions in combination with other activities (e.g., yoga and meditation) for different groups, namely early Alzheimer's disease, Semantic Dementia, and older individuals in the prison system.

Working alliance and adherence mediate the effect of guidance in a web-based program for participants with mild to moderate depressive symptoms: A secondary mediation analysis

Guided web-based self-help programs for individuals with depressive symptoms have shown to be more efficacious than unguided programs. However, research has paid little attention to why guided interventions are superior. The present study investigated whether working alliance and adherence to the program mediated the effect of guidance on depressive symptom outcome. The study is a secondary analysis of a randomized factorial trial. In the trial, 302 adults with mild to moderate depressive symptoms (Patient Health Questionnaire-9 score: 5-14) were randomized to either a guided or an unguided group. All participants received access to a web-based self-help program based on problem-solving therapy. Working alliance with the treatment providers was assessed using an adapted version of the Working Alliance Inventory for Guided Internet Interventions two weeks (early-treatment) and eight weeks (post-treatment) after pre-treatment. The primary outcome was depressive symptoms at post-treatment. The total working alliance score was significantly higher for guided participants compared to unguided participants (at early-treatment: t _248.6 = -3.36, p < .001, d = 0.42, at post-treatment: t _194.9 = -4.77, p < .001, d = 0.66). The total working alliance score correlated significantly with the change in depressive symptoms for guided (rs = 0.16, 0.34) and unguided participants (rs = 0.26, 0.23). The WAI-I total score statistically mediated the relationship between guidance and outcome (at early-treatment: B = -0.028, at post-treatment: B = -0.053). Furthermore, the subscale tasks (at post-treatment: B = -0.051), the subscale goals (at early-treatment: B = -0.031 and at post-treatment: B = -0.052), and adherence to the program (B = -0.034) mediated the relationship between guidance and outcome. Finally, in a multiple mediation model both early-treatment working alliance and adherence to the program (B = -0.050) mediated the relationship between guidance and outcome. These findings indicate that guidance increases working alliance to treatment providers as early as two weeks after treatment beginning. The alliance predicts outcome and mediates the relationship between guidance and outcome. Participants' agreement with tasks and goals of a program seems to be more important than the bond with treatment providers. Treatment providers might therefore attune web-based programs to the preferences and expectations of participants. In addition to the working alliance, adherence to the program co-mediates the relationship between guidance and outcome.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Technological Advances in Cognitive-Behavioral Therapy and Clinical Practice: Challenges in an Evolving Field

Technological innovations in cognitive-behavioral therapy (CBT) provide excellent opportunities for mental health clinicians to expand access to mental health treatment among culturally diverse and marginalized populations. This brief report highlights challenges that mental health clinicians encounter as they integrate technological innovations in CBT into their work with diverse clients and provides recommendations for addressing them. The authors identify five key challenges of using technology-driven CBT: development of the therapeutic alliance; potential fit for clients from culturally diverse backgrounds and marginalized groups; geographic and economic access; ethical and legal concerns; and competency in CBT practice, training, and supervision. Technological advances in CBT allow clinicians to treat more individuals from underserved communities. Existing challenges compel clinicians across disciplines to ensure that their practice is congruent with CBT practice values and ethics, policy, and research and that the best available CBT intervention can be integrated into all aspects of mental health practice.

The Use of Telehealth in Depression Treatment during the Crisis Caused by COVID-19

Throughout the COVID-19 pandemic, there has been increased interest in telehealth as a means of providing care for depression. In this article, we provide an overview of telehealth utilization for the treatment of depression and provide some insight into the rapid shift made to quickly implement these telehealth services into our everyday practices due to COVID-19 personal distancing requirements. We review the application of telehealth in the treatment of depression during the COVID-19 pandemic. The multiple advantages and disadvantages of telehealth in treatment of depression are summarized through the literature, and we analyze the methods to improve the effect and quality of telehealth in depression treatment. It has been highlighted in the current research that against its proven capacity for convenience, its relative cheapness, and its ability to overcome geographic barriers, telehealth has its own shortfalls, including disparities in rural-urban infrastructure and an alleged inability to be exhaustive when intensive interventions are needed. Recommendations for the improvement of telehealth during the COVID-19 pandemic also presuppose that it is infrastructure and human resource intensive and that short-term improvements in its efficiency are largely dependent on the creativity and resourcefulness of physicians to provide custom solutions for patients.

Awareness, Acceptability, and Perceived Effectiveness of Text-Based Therapy Among Graduate Students: Cross-sectional Study

Background

Research has suggested that there is a mental health crisis occurring among graduate students in the United States. Moreover, many students go without effective treatment owing to the limited availability of mental and behavioral health resources on college campuses. Text-based therapy may represent a viable method for increasing access to mental health support for graduate students, but little is known regarding its acceptability in this population.

Objective

The purpose of this study was to assess how graduate students perceive text-based therapy and their likelihood of seeking out this form of therapy.

Methods

In total, 265 graduate students completed a cross-sectional web-based survey that included multiple-choice and open-ended questions assessing their perceptions of text-based therapy and the likelihood of seeking out this form of therapy. Chi-square tests, ANOVAs, and nonparametric Wilcoxon signed-rank tests were used to examine differences in multiple-choice questions. The constant comparative method was used for qualitative analyses of the open-ended question responses.

Results

Participants (n=265) were predominately non-Hispanic White (166/265, 62.6%) and female (167/265, 63%) with a mean age of 28.3 (SD 5.1) years. Over half of the participants (139/265, 52.5%) were not aware that text-based therapy existed; however, 65.3% (173/265) reported that they would consider using text-based services, if available. In comparison to face-to-face therapy, participants reported being less likely to seek out text-based therapy and perceived it as less effective (P<.001). Qualitative results indicated that participants were concerned about the ability to effectively communicate and build rapport through text-based therapy and thought that this modality may be more effective for some mental and behavioral health concerns than others. Moreover, participants noted that text-based therapy would be best implemented as a way to supplement, rather than replace, face-to-face services.

Conclusions

Altogether, the results of this study suggest that text-based therapy holds the potential to increase access to and use of mental and behavioral health services; however, graduate students remain concerned about its effectiveness and the optimal methods of implementation. Future research should investigate how therapeutic processes (eg, effective communication and rapport-building) can be facilitated in digital environments and how text-based therapy could be best implemented to supplement and extend, rather than replace, face-to-face services.

Conceptual Invariance, Trajectories, and Outcome Associations of Working Alliance in Unguided and Guided Internet-Based Psychological Interventions: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

The role of working alliance remains unclear for many forms of internet-based interventions (IBIs), a set of effective psychotherapy alternatives that do not require synchronous interactions between patients and therapists.

OBJECTIVE

This study examined the conceptual invariance, trajectories, and outcome associations of working alliance across an unguided IBI and guided IBIs that incorporated clinician support through asynchronous text messaging or video messaging.

METHODS

Adults with high education attainment (n=145) with subclinical levels of anxiety, stress, or depressive symptoms were randomized to 1 of 3 treatment conditions for 7 weeks. All participants received treatments from MyCompass, an unguided IBI using cognitive behavior therapy. Participants in condition 2 and 3 received supplemental, asynchronous clinician support through text and video, respectively. Working alliance with the IBIs was measured weekly using select items from the 12-item version of the Agnew Relationship Measure. Symptom and functional outcomes were assessed at baseline, at the end of treatment, and 1-month follow-up.

RESULTS

Working alliance with the IBIs was conceptually invariant across the 3 conditions. Working alliance followed a quadratic pattern of change over time for all conditions and declined significantly only in the text-support condition. After controlling for baseline symptoms, higher baseline levels of working alliance predicted less depression and less functional impairment at follow-up, whereas faster increases in working alliance predicted less worry at the end of treatment and at follow-up, all of which only occurred in the video-support condition.

CONCLUSIONS

Working alliance with the IBIs was generally established in the initial sessions. Although working alliance is conceptually invariant across IBIs with or without clinician support, the associations between working alliance and treatment outcomes among IBIs may differ depending on clinician involvement and the modalities of support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05122429; https://clinicaltrials.gov/ct2/show/NCT05122429.

An integrated early care pathway for autism

In this Viewpoint, we argue for the need to reconceptualise an integrated early-care provision for autistic children in the light of their enduring support needs and relevant new findings from developmental and intervention research. This model goes beyond short-term reactive care to outline an early proactive, evidenced, developmentally phased, and scalable programme of support for autistic children and their families from the earliest opportunity, with timely access to later step-up care when needed. We also integrate this model with emerging opportunities from data science and digital health technologies as a potential facilitator of such a pathway. Building on this work, we argue that the best current autism intervention evidence can be integrated with concepts and evidence gained in the management of other enduring health conditions to support an autistic child and their family through their early development. The aim is to improve those children's social communication abilities, expand their range and flexibility of interests, and mitigate any negative impacts of sensory difficulties and restricted, repetitive behaviours on the child and their family wellbeing. The pathway solutions described could also be adapted for older adolescents and adults and could be used within the health systems of different countries, including within low-income and middle-income contexts.

Clinical Effectiveness of Blended CBT Compared vs Face-to-Face CBT for adult depression: a Randomised Controlled Non-Inferiority Trial (Preprint)

Background

Internet-based cognitive behavioral therapy (iCBT) has been demonstrated to be cost- and clinically effective. There is a need, however, for increased therapist contact for some patient groups. Combining iCBT with traditional face-to-face (FtF) consultations in a blended format may produce a new treatment format (B-CBT) with multiple benefits from both traditional CBT and iCBT, such as individual adaptation, lower costs than traditional therapy, wide geographical and temporal availability, and possibly lower threshold to implementation.

Objective

The primary aim of this study is to compare directly the clinical effectiveness of B-CBT with FtF-CBT for adult major depressive disorder.

Methods

A 2-arm randomized controlled noninferiority trial compared B-CBT for adult depression with treatment as usual (TAU). The trial was researcher blinded (unblinded for participants and clinicians). B-CBT comprised 6 sessions of FtF-CBT alternated with 6-8 web-based CBT self-help modules. TAU comprised 12 sessions of FtF-CBT. All participants were aged 18 or older and met the diagnostic criteria for major depressive disorder and were recruited via a national iCBT clinic. The primary outcome was change in depression severity on the 9-item Patient Health Questionnaire (PHQ-9). Secondary analyses included client satisfaction (8-item Client Satisfaction Questionnaire [CSQ-8]), patient expectancy (Credibility and Expectancy Questionnaire [CEQ]), and working (Working Alliance Inventory [WAI] and Technical Alliance Inventory [TAI]). The primary outcome was analyzed by a mixed effects model including all available data from baseline, weekly measures, 3-, 6, and 12-month follow-up.

Results

A total of 76 individuals were randomized, with 38 allocated to each treatment group. Age ranged from 18 to 71 years (SD 13.96) with 56 (74%) females. Attrition rate was 20% (n=15), which was less in the FtF-CBT group (n=6, 16%) than in the B-CBT group (n=9, 24%). As many as 53 (70%) completed 9 or more sessions almost equally distributed between the groups (nFtF-CBT=27, 71%; nB-CBT=26, 68%). PHQ-9 reduced 11.38 points in the FtF-CBT group and 8.10 in the B-CBT group. At 6 months, the mean difference was a mere 0.17 points. The primary analyses confirmed large and significant within-group reductions in both groups (FtF-CBT: β=–.03; standard error [SE] 0.00; P<.001 and B-CBT: β=–.02; SE 0.00; P<.001). A small but significant interaction effect was observed between groups (β=.01; SE 0.00; P=.03). Employment status influenced the outcome differently between groups, where the B-CBT group was seen to profit more from not being full-time employed than the FtF group.

Conclusions

With large within-group effects in both treatment arms, the study demonstrated feasibility of B-CBT in Denmark. At 6 months’ follow-up, there appeared to be no difference between the 2 treatment formats, with a small but nonsignificant difference at 12 months. The study seems to demonstrate that B-CBT is capable of producing treatment effects that are close to FtF-CBT and that completion rates and satisfaction rates were comparable between groups. However, the study was limited by small sample size and should be interpreted with caution.

Trial Registration

ClinicalTrials.gov NCT02796573; https://clinicaltrials.gov/ct2/show/NCT02796573

International Registered Report Identifier (IRRID)

RR2-10.1186/s12888-016-1140-y

Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster

BACKGROUND

Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND.

OBJECTIVE

This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT).

METHODS

In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up.

RESULTS

Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups.

CONCLUSIONS

In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364683&isReview=true.

Responsible Relations: A Systematic Scoping Review of the Therapeutic Alliance in Text-Based Digital Psychotherapy

Introduction: Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy. Text-based digital psychotherapy has become increasingly common, yet much remains unclear about the alliance and its importance for delivering mental health care via a digital format. To employ text-based digital therapies responsibly, more insight is needed into the type and strength of the therapeutic alliance online. Methods: A systematic scoping review was performed searching four databases: Scopus, PsycINFO, Web of Science, and Wiley Online Library. A total of 23 studies were selected and data was extracted and tabulated to explore the characteristics of studies on text-based psychotherapy, measurements of the therapeutic alliance and associations of the alliance with treatment outcome. Results: The therapeutic alliance in text-based digital interventions was studied with a variety of client groups, though mostly for clients diagnosed with anxiety and/or depression issues. Treatment modalities were predominantly internet-based cognitive behavioral therapy (ICBT) and tailored platforms for distinct client groups (e.g., PTSD). Almost all treatments used asynchronous text-based communication, such as e-mails and integrated messaging functions, which were mainly used to give feedback on tasks. For measurements, a version of the Working Alliance Inventory (WAI) was used in most studies. Measurements with the WAI or WAI- short form indicated a good therapeutic alliance with a weighted mean score of 5.66 (on a scale of 1 to 7) and a weighted standard deviation of 0.84. Relations between the therapeutic alliance and treatment outcomes were mostly positive, with many studies reporting significant associations (n = 8 out of 10) or significant effects of the therapeutic alliance on treatment outcomes (n = 5 out of 6). Discussion: Our scoping review suggests that a good therapeutic alliance can be established in digital psychotherapy through text-based communication, and shows support for a positive relationship between the alliance and treatment outcomes. These findings illustrate that text-based online psychotherapy can be a responsible treatment option as far as the establishment of the therapeutic alliance is concerned. However, current measures of the therapeutic alliance might miss important aspects of the alliance in digital treatment, such as the presence of empathy or compassion.

Psychotherapists' rated working alliance in an internet-based intervention for bereaved siblings

Bereaved siblings often receive insufficient social support and are at higher risk for mental disorders. This study aimed to examine the role of the therapist-rated working alliance in an online intervention for bereaved siblings. Clients (n = 74, 95% female), aged 17-59 received writing assignments and individual feedback by CBT trained therapists over 6 weeks. Working alliance (Working Alliance Inventory) and treatment outcomes (Inventory of Complicated Grief, Beck Depression Inventory-II) were assessed. Results revealed that the working alliance significantly increased during the course of the treatment and a significant association between working alliance and the change in depression was found.

Caregiver Response to an Online Dementia and Caregiver Wellness Education Platform

BACKGROUND

Web-based educational interventions are emerging as a potential solution to improve caregiver dementia knowledge and overall well-being.

OBJECTIVE

To assess the feasibility of delivering a web-based intervention for dementia caregivers by examining: 1) engagement with the online platform, 2) skill implementation, and 3) changes on outcome metrics over the 30-day study period.

METHODS

Enrolled participants were onboarded by a trained research coordinator and provided 24/7 access to the platform over 30 days. At study onset and completion, caregivers completed assessments of care recipient dementia severity and neuropsychiatric symptoms along with instruments which measured dementia knowledge, caregiver burden, and carer experience.

RESULTS

Of 84 referrals, 60 caregivers met study inclusion criteria and 55 completed pre and post study measures. Caregivers completed an average of 8 hours of learning over the 30-day web-based intervention, with 84.4%of participants reporting using at least one skill they learned from the online platform. Eighty-nine percent of participants reported high satisfaction with the web-based educational intervention. There were small effect sizes for decreases in NPIQ neuropsychiatric symptom severity and caregiver distress scores from pre- to post-intervention. Small effect sizes were observed for changes in caregiver burden from pre- to post-intervention among caregivers who perceived their care recipient as having high global deterioration.

CONCLUSION

Findings show online educational programs are feasible for informal family caregivers of dementia and have perceived value. Future studies should address caregiver response to online education in less severe versus more severe care recipients, and explore the value of caregiver online platforms in diverse caregiver samples.

Evidence of Human-Level Bonds Established With a Digital Conversational Agent: Cross-sectional, Retrospective Observational Study

Background

There are far more patients in mental distress than there is time available for mental health professionals to support them. Although digital tools may help mitigate this issue, critics have suggested that technological solutions that lack human empathy will prevent a bond or therapeutic alliance from being formed, thereby narrowing these solutions’ efficacy.

Objective

We aimed to investigate whether users of a cognitive behavioral therapy (CBT)–based conversational agent would report therapeutic bond levels that are similar to those in literature about other CBT modalities, including face-to-face therapy, group CBT, and other digital interventions that do not use a conversational agent.

Methods

A cross-sectional, retrospective study design was used to analyze aggregate, deidentified data from adult users who self-referred to a CBT-based, fully automated conversational agent (Woebot) between November 2019 and August 2020. Working alliance was measured with the Working Alliance Inventory-Short Revised (WAI-SR), and depression symptom status was assessed by using the 2-item Patient Health Questionnaire (PHQ-2). All measures were administered by the conversational agent in the mobile app. WAI-SR scores were compared to those in scientific literature abstracted from recent reviews.

Results

Data from 36,070 Woebot users were included in the analysis. Participants ranged in age from 18 to 78 years, and 57.48% (20,734/36,070) of participants reported that they were female. The mean PHQ-2 score was 3.03 (SD 1.79), and 54.67% (19,719/36,070) of users scored over the cutoff score of 3 for depression screening. Within 5 days of initial app use, the mean WAI-SR score was 3.36 (SD 0.8) and the mean bond subscale score was 3.8 (SD 1.0), which was comparable to those in recent studies from the literature on traditional, outpatient, individual CBT and group CBT (mean bond subscale scores of 4 and 3.8, respectively). PHQ-2 scores at baseline weakly correlated with bond scores (r=−0.04; P<.001); however, users with depression and those without depression had high bond scores of 3.45.

Conclusions

Although bonds are often presumed to be the exclusive domain of human therapeutic relationships, our findings challenge the notion that digital therapeutics are incapable of establishing a therapeutic bond with users. Future research might investigate the role of bonds as mediators of clinical outcomes, since boosting the engagement and efficacy of digital therapeutics could have major public health benefits.

Internet-based cognitive behavioural therapy programme with and without videoconference guidance sessions: A randomized controlled trial to treat work-related symptoms of anxiety and depression

This study provides the results from the implementation of a highly structured therapist-guided iCBT programme for people with work-related anxiety and depression, in terms of programme efficacy, participants' adherence and satisfaction. Seventy-seven national police workers were randomly allocated to one of two groups: without additional videoconference sessions (web platform with guidance of therapist) and with additional videoconference sessions (same intervention as the previous group, plus two videoconference guidance sessions with a psychologist). The intervention was composed of 12 sessions and took place for 17-20 weeks. We found an adherence rate of 36.4%, with no differences between groups. All participants endorsed lower depression (BDI-II F(1) = 36.98, p < .001; ATQ F(1) = 24.22, p < .001), and anxiety (STAI-State F(1) = 76.62, p < .001) after the programme. As a variable related to anxiety and depression in workplace, participants also showed higher assertiveness levels (RAS F(1) = 8.96, p < .001). A significant reduction of the mean level of anxiety perceived by participants as the intervention programme progressed was observed in both groups (F(2) = 7.44; p = .003). Participants were satisfied with the therapists' intervention and with the programme. No significant group effects were found for any of the measures. Reduction in depression levels was maintained in the 12-month follow-up, but levels of anxiety increased. This study is innovative, as it is the first controlled trial to analyse the effect of two added videoconference sessions, and it includes short- and long-term measures, which is not usual. The results are discussed to clarify the role of the contact with the therapist to improve treatment adherence.

Implementing Videoconference CBT for Depression in Routine Outpatient Care: Outcome, Working Alliance, and Influence of Patients’ Technology Commitment

<b><i>Background:</i></b> While videoconference cognitive behavioral therapy (V-CBT) has shown promising results in controlled studies, data from routine care are rare. We examined (1) changes in depressive symptoms and life satisfaction during V-CBT in German routine outpatient care for patients with depressive disorders, (2) the quality of the established working alliance, and (3) the influence of working alliance and the patients’ technology commitment on outcomes. <b><i>Patients and Methods:</i></b> Patients with primary diagnoses of depressive disorders were treated with V-CBT and concurrent internet-guided self-help via the MindDoc program, which operates within the regulations of the German health care system. The patients completed the 9-item Patient Health Questionnaire (PHQ-9) for depressive symptoms, an item on life satisfaction before and after treatment, the Working Alliance Inventory (WAI), and the Technology Commitment questionnaire for beliefs about handling technology. <b><i>Results:</i></b> Fifty-nine patients (71.2% female) with a mean age of 44.46 years (SD = 12.86) were included in the analyses. Longitudinal multilevel mixed models revealed improvements in depressive symptoms (Cohen’s <i>d</i> = 1.27) and life satisfaction (<i>d</i> = 0.80). The working alliance was good and showed a positive association with outcome, while technology commitment did not. <b><i>Conclusion:</i></b> V-CBT seems effective in reducing depressive symptoms, increasing life satisfaction, and establishing a good working alliance in routine care.

Therapeutic alliance across trauma-focused and non-trauma-focused psychotherapies among veterans with PTSD

Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are not widely utilized. Clinicians report concerns that direct discussion of traumatic experiences could undermine the therapeutic alliance, which may negatively impact retention and outcome. Studies among adolescents with PTSD found no difference in alliance between trauma-focused and non-trauma-focused psychotherapies, but this has not been tested among adults. The present study is a secondary analysis of a randomized trial of collaborative care, also known as care management, for PTSD. We examined patient-reported therapeutic alliance among 117 veterans with PTSD who participated in cognitive processing therapy (CPT, now called CPT + A; n = 54) or non-trauma-focused supportive psychotherapy for PTSD (n = 73) at VA community outpatient clinics. We tested the hypothesis that alliance in CPT would be noninferior to (i.e., not significantly worse than) non-trauma-focused psychotherapy using patient ratings on the Revised Helping Alliance Questionnaire. Patients' therapeutic alliance scores were high across both groups (CPT: M = 5.13, SD = 0.71, 95% CI [4.96, 5.30]; non-trauma-focused psychotherapy: M = 4.89, SD = 0.64, 95% CI [4.73, 5.05]). The difference between groups (0.23, 95% CI [0.01, 0.48]) was less than the "noninferiority margin" based on suggested clinical cutoffs (0.58 points on a 1-6 scale). These results held even after adjusting for veterans' demographic and clinical characteristics and change in PTSD symptoms from baseline to follow-up. Although there are concerns that direct discussion of traumatic experiences could worsen therapeutic alliance, patients report similar levels of alliance in CPT and non-trauma-focused supportive psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Working Alliance Inventory for Online Interventions-Short Form (WAI-TECH-SF): The Role of the Therapeutic Alliance between Patient and Online Program in Therapeutic Outcomes

Background: Therapeutic alliance (TA) between the patient and therapist has been related to positive therapeutic outcomes. Because Internet-based interventions are increasingly being implemented, a tool is needed to measure the TA with Internet-based self-guided programs. The Working Alliance Inventory for online interventions (WAI-TECH-SF) was adapted based on the WAI Short Form (Hatcher & Gillaspy, 2006). The objectives of this study were: (1) to analyse the psychometric properties of the WAI-TECH-SF; (2) to explore the differences in the WAI-TECH-SF scores according to different categories of the sample; and (3) to analyse whether the WAI-TECH-SF can predict therapeutic outcomes and satisfaction with the treatment. Methods: 193 patients diagnosed with depression were included and received blended Cognitive-Behavioural Therapy. Measures of preferences, satisfaction, and credibility about the treatment, TA with the online program, depressive symptoms, and satisfaction with the treatment were administered. Results: An exploratory factor analysis revealed a one-dimensional structure with adequate internal consistency. Linear regression analyses showed that the WAI-TECH-SF predicted changes in depressive symptoms and satisfaction with the treatment. Conclusions: WAI-TECH-SF is a reliable questionnaire to assess the TA between the patient and the online program, which is associated with positive therapeutic outcomes and satisfaction with the treatment.

The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review

BACKGROUND

Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses.

OBJECTIVE

This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses.

METHODS

A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance.

RESULTS

Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features.

CONCLUSIONS

More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

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

The Association of Therapeutic Alliance With Long-Term Outcome in a Guided Internet Intervention for Depression: Secondary Analysis From a Randomized Control Trial

BACKGROUND

Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes.

OBJECTIVE

The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties.

METHODS

A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment.

RESULTS

We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ₀₂=-1.74, standard error [SE]=0.40, 95% CI -2.52 to -0.96, t₂₀₆=-4.37, P<.001) and patient well-being (γ₀₂=3.10, SE=1.14, 95% CI 0.87-5.33, t₁₉₈=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68).

CONCLUSIONS

The results of this study point out the importance of attuning internet interventions to patients' expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient's individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

Working Alliance in Blended Versus Face-to-Face Cognitive Behavioral Treatment for Patients with Depression in Specialized Mental Health Care

This study investigates working alliance in blended cognitive behavioral therapy (bCBT) for depressed adults in specialized mental health care. Patients were randomly allocated to bCBT (n = 47) or face-to-face CBT (n = 45). After 10 weeks of treatment, both patients and therapists in the two groups rated the therapeutic alliance on the Working Alliance Inventory Short-Form Revised (WAI-SR; Task, Bond, Goal, and composite scores). No between-group differences were found in relation to either patient or therapist alliance ratings, which were high in both groups. In the full sample, a moderate positive association was found between patient and therapist ratings on Task (ρ = 0.41, 95% CI 0.20; 0.59), but no significant associations emerged on other components or composite scores. At 30 weeks, within-and between-group associations between alliance and changes in depression severity (QIDS, Quick Inventory of Depressive Symptomatology) were analyzed with linear mixed models. The analyses revealed an association between depression over time, patient-rated alliance, and group (p < 0.001). In face-to-face CBT, but not in bCBT, lower depression scores were associated with higher alliance ratings. The online component in bCBT may have led patients to evaluate the working alliance differently from patients receiving face-to-face CBT only.

Internet-Delivered Cognitive Behavior Therapy as a Prequel to Face-To-Face Therapy for Depression and Anxiety: A Naturalistic Observation

Background: The UK's Improving Access to Psychological Therapies (IAPT) program is a stepped-care model treating individuals with depression and anxiety disorders. Internet-delivered cognitive behavioral therapy (iCBT) is routinely offered to individuals with mild to moderate symptoms, but its applicability to individuals with severe clinical symptoms and requiring a high-intensity intervention is relatively unknown. The current study sought to investigate the potential impacts of using iCBT as a prequel for patients requiring high-intensity treatment (HIT; face-to-face) for depression and anxiety in IAPT. Methods: The study utilized an open study design. One hundred and twenty-four participants who were on a waiting list for high-intensity, face-to-face psychological treatment were offered iCBT. Psychometric data on symptoms of depression, anxiety, and functioning were collected from participants before starting and on finishing iCBT and at the point of service exit. Therapeutic alliance data were collected from patients and clinicians during treatment. Patient pathway data, such as number of treatment sessions and time in treatment, was also collected and incorporated into the analysis. Results: Significant reductions across primary outcome measures of depression and anxiety, as well as improved functioning, were observed from baseline to iCBT treatment exit, and from iCBT exit to service exit. Analysis of the therapeutic alliance data for patients and clinicians illustrated differences in outcome for those who dropped out and those who completed treatment. Discussion: This study illustrates the potential for using iCBT as a prequel to high-intensity therapy for depression and anxiety disorders and is the first of its kind to do so within IAPT stepped care. The results show that iCBT is a valuable option reducing waiting times and enhancing clinical efficiency. The study contributes to the well-established evidence on online psychological treatments worldwide, but further clinical and service development research is necessary to scale these treatments appropriately.

@myTabu-A Placebo Controlled Randomized Trial of a Guided Web-Based Intervention for Individuals Who Sexually Abused Children and Individuals Who Consumed Child Sexual Exploitation Material: A Clinical Study Protocol

Background: There is a high demand for evidence-based and cost-effective treatment concepts for convicted individuals who sexually abused children (ISAC) and individuals who consumed child sexual exploitation material (ICCSEM) under community supervision (CS). The @myTabu-consortium developed a guided web-based intervention for convicted ISAC and ICCSEM under CS consisting of six online modules targeting psychological meaningful risk factors. The study aims to evaluate the effectiveness of this guided web-based intervention in reducing dynamic risk factors and the risk to re-offend compared to a placebo condition. Furthermore, these dynamic risk factors are measured before and after every module to evaluate their individual effectiveness to reduce the respective risk factor as well as risk to re-offend. This clinical trial protocol describes the planned methods as well as the intervention concept. Methods: The methodological design is a placebo controlled randomized add-on trial (N = 582) with follow-ups at 8 points in time. The placebo condition controls for attention and expectation effects and comprises the same amount of modules with a comparable temporal effort as the experimental intervention. The trial is conducted as an add-on to community supervision as usually done. Primary outcomes are dynamic risk factors assessed by self-report risk assessment tools and officially recorded re-offenses. Discussion: To the best of our knowledge, the study is the first to compare the (cost-) effectiveness of a guided web-based intervention for convicted ISAC and ICCSEM under community supervision against a placebo condition. Methodological limitations (e.g., potential ceiling- or volunteers-effects) are discussed. Clinical Trial Registration: German Clinical Trial Register (DRKS 00021256). Prospectively registered: 24.04.2020.

Personality as predictor of outcome in internet-based treatment of bulimic eating disorders

Internet-based cognitive behavioral therapy (ICBT) for bulimic eating disorders has demonstrated clinical utility and cost efficiency, but is associated with low patient preference, low credibility, sizeable dropout and only moderate symptom reduction. To improve outcome it is imperative to learn more about who might benefit from internet-based interventions. To do this, the current study investigated the Five Factor Model of personality as predictor of outcome in patients with full or sub-threshold bulimia nervosa (n = 109). Patients in a randomized controlled trial of ICBT were assessed prior to and at the end of treatment. Patients showed significant symptom reduction over time (Cohen's d = 1.0, p < .001). Remission as well as overall symptom reduction was positively predicted by Openness to Experience and Conscientiousness. Binge eating cessation specifically, was positively predicted by Extraversion. The study supports the use of personality assessment for patient selection and outcome optimization in internet-based treatment of bulimic eating disorders.

Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial

Background

Mindfulness-based cognitive therapy (MBCT) is an evidence-based group-based psychological treatment in oncology, resulting in reduction of depressive and anxiety symptoms. Internet-based MBCT (eMBCT) has been found to be an effective alternative for MBCT. The therapeutic alliance (the bond between therapist and patient,) is known to have a significant impact on psychological treatment outcomes, including MBCT. A primary concern in the practice of eMBCT is whether a good therapeutic alliance can develop. Although evidence for the beneficial effect of therapist assistance on treatment outcome in internet-based interventions (IBIs) is accumulating, it is still unclear whether the therapeutic alliance is related to outcome in IBIs.

Objective

This study aimed to (1) explore whether early therapeutic alliance predicts treatment dropout in MBCT or eMBCT, (2) compare the development of the therapeutic alliance during eMBCT and MBCT, and (3) examine whether early therapeutic alliance is a predictor of the reduction of psychological distress and the increase of mental well-being at posttreatment in both conditions.

Methods

This study was part of a multicenter randomized controlled trial (n=245) on the effectiveness of MBCT or eMBCT for distressed cancer patients. The therapeutic alliance was measured at the start of week 2 (ie, early therapeutic alliance), week 5, and week 9. Outcome measures were psychological distress, measured with the Hospital Anxiety and Depression Scale, and mental well-being, measured with the Mental Health Continuum-Short Form.

Results

The strength of early therapeutic alliance did not predict treatment dropout in MBCT or eMBCT (B=−.39; P=.21). Therapeutic alliance increased over time in both conditions (F_2,90=16.46; Wilks λ=0.732; P<.001). This increase did not differ between eMBCT and MBCT (F_1,91=0.114; P=.74). Therapeutic alliance at week 2 predicted a decrease in psychological distress (B=−.12; t₁₁₄=−2.656; P=.01) and an increase in mental well-being (B=.23; t₁₁₃=2.651; P=.01) at posttreatment. The relationship with reduction of psychological distress differed between treatments: a weaker early therapeutic alliance predicted higher psychological distress at posttreatment in MBCT but not in eMBCT (B=.22; t₁₁₃=2.261; P=.03).

Conclusions

A therapeutic alliance can develop in both eMBCT and MBCT. Findings revealed that the strength of early alliance did not predict treatment dropout. Furthermore, the level of therapeutic alliance predicted reduced psychological distress and increased mental well-being at posttreatment in both conditions. Interestingly, the strength of therapeutic alliance appeared to be more related to treatment outcome in group-based MBCT than in eMBCT.

Trial Registration

ClinicalTrials.gov NCT02138513; https://clinicaltrials.gov/ct2/show/NCT02138513

Women's expectations and experiences regarding e-health treatment: A systematic review

There is a gap in knowledge of women's perceptions of e-health treatment. This review aims to investigate women's expectations and experiences regarding e-health. A search was conducted in MEDLINE, EMBASE, CINAHL and PsycInfo in March 2016. We included articles published between 2000 and March 2016, reporting on e-health interventions. The initial search yielded 2987 articles. Eventually, 16 articles reporting on 16 studies were included. Barriers to e-health treatment were lower for women than barriers to face-to-face treatment, such as feelings of shame and time constraints. Women were able to develop an online therapeutic relationship. As reduced feelings of obligation and lack of motivation were women's greatest challenges in completing e-health treatment, they expressed a wish for more support during e-health treatment, preferably blended care. e-Health lowers the threshold for women to seek healthcare. Combining e-health interventions with face-to-face sessions may enhance women's motivation to complete treatment.

Interrelations between participant and intervention characteristics, process variables and outcomes in online interventions: A protocol for overarching analyses within and across seven clinical trials in ICare

BACKGROUND

It is well known that web-based interventions can be effective treatments for various conditions. Less is known about predictors, moderators, and mediators of outcome and especially interrelations between participant and interventions characteristics, process variables and outcomes in online interventions. Clinical trials often lack statistical power to detect variables that affect intervention effects and their interrelations. Within ICare, we can investigate the interrelation of potential predictor and process variables in a large sample.

METHOD

The ICare consortium postulated a model of interrelations between participant and intervention characteristics, process variables and outcomes in online interventions. We will assess general and disorder-specific interrelations between characteristics of the intervention, characteristics of the participants, adherence, working alliance, early response, and intervention outcomes in a sample of over 7500 participants from seven clinical trials evaluating 15 online interventions addressing a range of mental health conditions and disorders, using an individual participant data meta-analyses approach.

DISCUSSION/CONCLUSION

Existing research tends to support the efficacy of online mental health interventions, but the knowledge base regarding factors that affect intervention effects needs to be expanded. The overarching analyses using data from the ICare intervention trials will add considerably to the evidence.

A telemedicine platform to improve clinical parameters in paranoid schizophrenia patients: Results of a one-year randomized study

OBJECTIVE

The study objective was to test a smartphone-based MONEO platform designed to improve the clinical condition of paranoid schizophrenia patients. Telemedicine treatment is considered to be as effective as traditional treatment in outpatient clinics.

METHOD

A total of 290 patients with paranoid schizophrenia in the symptomatic remission state were recruited to this 12-month multicenter, open-label randomized trial. A study group (n = 191) received a smartphone with the MONEO platform installed. Patients conducted cognitive training twice a week. Patients' mental state was assessed every month via teleconference. A placebo group (n = 99) received a platform with functionality limited to monthly teleconsultation and performing cognitive training every 6 months. The clinical status was measured using the Positive and Negative Syndrome Scale (PANSS), Calgary, and Clinical Global Impression-Severity (CGI-S) clinical scales.

RESULTS

After 12 months, a significant reduction of symptoms was observed in the study group, as assessed using the Calgary (36%, P < 0.01) and PANSS (8.6%, P < 0.05) scales. Symptom reduction of 23.6% was also observed in the placebo group (P < 0.05, Calgary scale). In the study group, depression, positive symptoms, excitement, general psychopathology and disorganization subscales decreased significantly, while in the placebo group, only the depression subscale decreased. The greatest improvement of 11.2% (study group, P < 0.05), vs 16.2% (placebo group, P < 0.05), was observed for the depression subscale.

CONCLUSION

The MONEO platform was demonstrated to positively influence the clinical condition of individuals with paranoid schizophrenia. A lack of negative consequences associated with usage of the device was also reported.

Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications

Mental disorders are highly prevalent and often remain untreated. Many limitations of conventional face-to-face psychological interventions could potentially be overcome through Internet-based and mobile-based interventions (IMIs). This chapter introduces core features of IMIs, describes areas of application, presents evidence on the efficacy of IMIs as well as potential effect mechanisms, and delineates how Artificial Intelligence combined with IMIs may improve current practices in the prevention and treatment of mental disorders in adults. Meta-analyses of randomized controlled trials clearly show that therapist-guided IMIs can be highly effective for a broad range of mental health problems. Whether the effects of unguided IMIs are also clinically relevant, particularly under routine care conditions, is less clear. First studies on IMIs for the prevention of mental disorders have shown promising results. Despite limitations and challenges, IMIs are increasingly implemented into routine care worldwide. IMIs are also well suited for applications of Artificial Intelligence and Machine Learning, which provides ample opportunities to improve the identification and treatment of mental disorders. Together with methodological innovations, these approaches may also deepen our understanding of how psychological interventions work, and why. Ethical and professional restraints as well as potential contraindications of IMIs, however, should also be considered. In sum, IMIs have a high potential for improving the prevention and treatment of mental health disorders across various indications, settings, and populations. Therefore, implementing IMIs into routine care as both adjunct and alternative to face-to-face treatment is highly desirable. Technological advancements may further enhance the variability and flexibility of IMIs, and thus even further increase their impact in people's lives in the future.

[Quality criteria of internet-based cognitive-behavioral interventions for children and adolescents and their parents - A systematic review]

Quality criteria of internet-based cognitive-behavioral interventions for children and adolescents and their parents - A systematic review Abstract. Introduction: This study provides an overview of existing internet-based evidence-based cognitive behavioral interventions (iCBT) for children/adolescents and their parents. The studies were evaluated based on preliminary defined quality criteria regarding their usability in the healthcare system. Methods: The review was performed according to PRISMA guidelines and evaluated the scientific literature concerning to iCBT. We conducted a comprehensive literature search of PubMed, PsychINFO, PsychARTICLES, PsychNDEX and Science Direct using relevant keywords. Studies were rated according to 10 previously predefined quality measures. Results: A total of 4,479 articles were screened, 62 of which were selected for further analysis. Thereof, 24 international iCBT programs with 50 randomized controlled trials (RCTs) were evaluated and met the quality criteria (M = 7.25, SD = 1.07). Further 13 publications showed preliminary efficacy for another 11 international iCBT programs and met the quality criteria (M = 7.45, SD = .82). There was no significant difference between programs evaluated within and without RCTs t(33) = -.56, p = .58. Conclusions: Our results indicate that multiple international iCBT programs exist. Because in Germany the waiting time for psychotherapeutic or psychiatric treatment is still about five months, iCBT programs have the potential to reduce this gap.

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.

Systematic review with meta-analysis: online psychological interventions for mental and physical health outcomes in gastrointestinal disorders including irritable bowel syndrome and inflammatory bowel disease

BACKGROUND

Online psychotherapy has been successfully used as supportive treatment in many chronic illnesses. However, there is a lack of evidence on its role in the management of gastrointestinal (GI) diseases.

AIMS

To examine whether online psychological interventions improve mental and physical outcomes in gastrointestinal diseases.

METHODS

We searched CINAHL Plus, MEDLINE, EMBASE, Health Management Information Consortium, PsycINFO, British Nursing Index, Cochrane Library, a specialised register of the IBD/FBD Cochrane Group, MEDLINE (PubMed) WHO International Clinical Trial Registry, ClinicalTrials.gov, and reference lists of all papers included in the review. The Cochrane Risk of Bias Tool was used to assess internal validity. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

We identified 11 publications (encompassing nine studies) meeting inclusion criteria. One study had a high risk of selection bias (allocation concealment), all studies had a high risk of performance and detection bias. Eight studies were included in the meta-analyses (6 on irritable bowel syndrome [IBS] and two on inflammatory bowel disease [IBD]). Online cognitive behavioural therapy (CBT) was shown to significantly improve gastrointestinal symptom-specific anxiety (MD: -8.51, 95% CI -12.99 to -4.04, P = 0.0002) and lessen symptom-induced disability (MD: -2.78, 95% CI -5.43 to -0.12, P = 0.04) in IBS post intervention. There was no significant effect of online CBT on any other outcomes in IBS. No significant effect of online psychotherapy was demonstrated in IBD.

CONCLUSION

There is insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases.

Internet- and Mobile-Based Psychological Interventions: Applications, Efficacy, and Potential for Improving Mental Health

Abstract. The majority of mental health disorders remain untreated. Many limitations of traditional psychological interventions such as limited availability of evidence-based interventions and clinicians could potentially be overcome by providing Internet- and mobile-based psychological interventions (IMIs). This paper is a report of the Taskforce E-Health of the European Federation of Psychologists’ Association and will provide an introduction to the subject, discusses areas of application, and reviews the current evidence regarding the efficacy of IMIs for the prevention and treatment of mental disorders. Meta-analyses based on randomized trials clearly indicate that therapist-guided stand-alone IMIs can result in meaningful benefits for a range of indications including, for example, depression, anxiety, insomnia, or posttraumatic stress disorders. The clinical significance of results of purely self-guided interventions is for many disorders less clear, especially with regard to effects under routine care conditions. Studies on the prevention of mental health disorders (MHD) are promising. Blended concepts, combining traditional face-to-face approaches with Internet- and mobile-based elements might have the potential of increasing the effects of psychological interventions on the one hand or to reduce costs of mental health treatments on the other hand. We also discuss mechanisms of change and the role of the therapist in such approaches, contraindications, potential limitations, and risk involved with IMIs, briefly review the status of the implementation into routine health care across Europe, and discuss confidentiality as well as ethical aspects that need to be taken into account, when implementing IMIs. Internet- and mobile-based psychological interventions have high potential for improving mental health and should be implemented more widely in routine care.

Working alliance with an avatar: How far can we go with internet interventions?

OBJECTIVE

To examine the working alliance between users and an avatar and users' treatment expectations in an unguided Internet intervention for the treatment of insomnia.

METHODS

The sample included participants from the treatment condition (N = 29) of a randomised controlled trial. The task and goal subscales of the Working Alliance Inventory Short Revised (WAI-SR) were applied in week three. Five items of the Bern Post-Session Report and one question about the extent to which users had missed a human therapist were administered after each session. Treatment expectations were measured with the Credibility Expectancy Questionnaire (CEQ), and the Insomnia Severity Index (ISI) was used as the primary outcome measure.

RESULTS

The mean scores for the WAI-SR task and goal subscales were relatively high (M = 3.24, SD = 0.79; M = 3.16, SD = 0.91, respectively). The mean score of the five Bern Post-Session Report items remained stable over time, but some users increasingly indicated that they missed a real therapist over the course of the intervention, with a strong linear effect (t(87) = 3.16, p < 0.01). ISI chance score was predicted by the mean score of the Bern Post-Session Report (b = -0.3.83, t(21.80) = -2.97, p < 0.01), missing a human therapist (b = -0.0.13, t(20.47) = -2.72, p = 0.01) and the CEQ (b = 0.18, t(19.03) = -2.69, p = 0.01), but not by WAI-SR task and goal subscales.

CONCLUSIONS

Results indicate that users established a working alliance with the avatar. The affective bond remained stable over time, but towards the end of the intervention some users indicated that they missed having a human therapist. Affective bond and missing a real therapist predicted symptom change.

The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta-analytic review

Research consistently provides evidence for the relationship between the therapeutic alliance (TA) and outcome across various therapies and presenting problems. Depression is considered the leading cause of disability worldwide, and there is substantial evidence for the efficacy for Cognitive Behaviour Therapy (CBT) in its treatment. At present, there is lack of clarity specifically about the relationship between the TA and outcome in CBT for depression. The present review is the first meta-analytic review to explore this relationship and also considering moderators. Within a random-effects model, an overall mean effect size of r = 0.26 (95% CI [.19-.32]) was found, indicating that the TA was moderately related to outcome in CBT for depression. The mean TA-outcome correlation is consistent with existing meta-analysis that looked across a broad range of presenting problems and psychological therapies. A secondary exploratory analysis of moderators suggested the TA-outcome relationship varied according to the TA rater, where the relationship was weaker for therapist raters compared with clients and observer raters. Additionally, the results indicated that the TA-outcome relationship marginally increased over the course of CBT treatment. The results of the meta-analysis are discussed in reference to the wider body of research, methodological limitations, clinical implications, and future directions for research.

My care manager, my computer therapy and me: The relationship triangle in computerized cognitive behavioural therapy

Previous research has reported mixed findings regarding the relationship between therapeutic alliance, engagement and outcomes in e-mental health. This study aims to overcome some of the methodological limitations of previous research and extend our understanding of alliance-outcome relationships in e-mental health by exploring the nature of the relationship triangle between the patient, their care manager and their computerized cognitive behavioural therapy (CCBT) program, accessed with or without an Internet Support Group (ISG). Positive patient-rated alliance with both their care manager and the CCBT program itself was found and these were significantly associated with measures of engagement and clinical outcome. The magnitude of this association was moderate, and within the range of that reported for traditional face-to-face psychotherapies in recent meta-analyses. Limitations of the study, including the reliance on completer data and a cross-sectional design, and directions for future research are presented. Our findings suggest that both the training and supervision of support staff and the optimization of CCBT interventions themselves to enhance alliance and experience may lead to improved engagement and outcomes.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01482806https://www.clinicaltrials.gov/ct2/show/NCT01482806?term=rollman&rank=4.

Aliança Terapêutica nas Terapias Cognitivo-comportamentais por Videoconferência: uma Revisão da Literatura

Resumo Nos últimos anos houve um aumento do número de usuários da internet no Brasil e no mundo, enquanto as intervenções por videoconferência surgiram como formas de tratamento para diversos transtornos mentais. Sabe-se que a aliança terapêutica é um componente essencial para se implementar a prática psicoterapêutica, porém, não há um consenso sobre sua formação na psicoterapia por videoconferência. Portanto, o presente artigo teve como objetivo realizar uma revisão de literatura acerca da formação e papel da aliança terapêutica nas Terapias Cognitivo-comportamentais (TCC) por videoconferência. Para isso, foi realizada uma busca em quatro bases de dados, Pubmed, Psycarticles, Lilacs e SciELO, com descritores específicos dos dicionários de cada base. No total, foram encontrados 365 artigos, mas apenas nove preencheram os critérios de inclusão baseados no objetivo deste estudo. Observou-se que a maioria dos artigos indicou que a aliança foi alta no decorrer das sessões de TCC por videoconferência, podendo ser comparada com a aliança formada na terapia presencial, e que poucos artigos avaliaram a aliança como fator preditivo de resultados e de adesão. Apesar deste indicativo, este estudo discute as limitações metodológicas dos artigos e indica a necessidade de estudos que tornem mais claras as evidências sobre a formação da aliança e o o seu papel nesta modalidade alternativa de tratamento.