Internet-based psychological treatments for depression

Prescription Digital Therapeutics for Substance Use Disorder in Primary Care: Mixed Methods Evaluation of a Pilot Implementation Study

BACKGROUND

Delivering prescription digital therapeutics (ie, evidence-based interventions designed to treat, manage, or prevent disorders via websites or smartphone apps) in primary care could increase patient access to substance use disorder (SUD) treatments. However, the optimal approach to implementing prescription digital therapeutics in primary care remains unknown.

OBJECTIVE

This pilot study is a precursor to a larger trial designed to test whether implementation strategies (practice facilitation [PF] and health coaching [HC]) improve the delivery of prescription digital therapeutics for SUDs in primary care. This mixed methods study describes outcomes among patients in the 2 pilot clinics and presents qualitative findings on implementation.

METHODS

From February 10 to August 6, 2021, a total of 3 mental health specialists embedded in 2 primary care practices of the same integrated health system were tasked with offering app-based prescription digital therapeutics to patients with SUD. In the first half of the pilot, implementation activities included training and supportive tools. PF (at 1 clinic) and HC (at 2 clinics) were added in the second half. All study analyses relied on secondary data, including electronic health records and digital therapeutic vendor data. Primary outcomes were the proportion of patients reached by the prescription digital therapeutics and fidelity related to ideal use. We used qualitative methods to assess the adherence to planned activities and the barriers and facilitators to implementing prescription digital therapeutics.

RESULTS

Of all 18 patients prescribed the apps, 10 (56%) downloaded the app and activated their prescription, and 8 (44%) completed at least 1 module of content. Patients who activated the app completed 1 module per week on average. Ideal use (fidelity) was defined as completing 4 modules per week and having a monthly SUD-related visit; 1 (6%) patient met these criteria for 10 weeks (of the 12-week prescription period). A total of 5 (28%) patients had prescriptions while HC was available, 2 (11%) were successfully contacted, and both declined coaching. Clinicians reported competing clinical priorities, technical challenges, and logistically complex workflows in part because the apps required a prescription. Some pilot activities were impacted by staff turnover that coincided with the COVID-19 pandemic. The facilitators to implementation were high engagement and the perception that the apps could meet patient needs.

CONCLUSIONS

The pilot study encountered the barriers to implementing prescription digital therapeutics in a real-world primary care setting, especially staffing shortages, turnover, and competing priorities for clinic teams. The larger randomized trial will clarify the extent to which PF and HC improve the implementation of digital therapeutics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04907045; https://clinicaltrials.gov/study/NCT04907045.

A guide for self-help guides: best practice implementation

Guided self-help is an evidence-based intervention used globally. Self-help is a fundamental part of the stepped care model of mental health services that enables the efficient use of limited resources. Despite its importance, there is little information defining the role of the guide and the key competences required. In this context, the guide is defined as the person who facilitates and supports the use self-help materials. This article sets out the role of the guide in guided self-help. It considers practical issues such as the importance of engagement to motivate clients for early change, personalising the intervention, structuring sessions, how best to use routine outcome monitoring and supervision requirements. Key competences are proposed, including generic competences to build the relationship as well as specific competences such as being able to clearly convey the role of the guide to clients. Guides should be prepared for "self-help drift", a concept akin to therapist drift in more traditional therapies. Knowing how to identify mental health problems, use supervision and manage risk and comorbidity are all key requirements for guides. The paper concludes by calling for increased recognition and value of the role of the guide within mental health services.

The Connected We St@nd programme: A feasibility pilot study of an online self-management intervention for adults on in-centre haemodialysis and family caregivers

OBJECTIVE

The 'Connected We St@nd' is an online self-management intervention programme for people receiving in-centre haemodialysis and family caregivers that combines an educational and psychosocial support component. This study aimed to evaluate its feasibility and acceptability before proceeding to a large-scale trial.

DESIGN

This was a pre-post single-arm feasibility pilot study conducted with adults undergoing in-centre haemodialysis and family caregivers.

METHODS

Feasibility was based on eligibility, consent, retention, completion and intervention adherence rates, while acceptability was assessed in post-intervention focus group interviews.

RESULTS

Twenty-six people (16 adults on haemodialysis and 10 family caregivers) recruited through social networks completed the intervention. Consent, retention and completion rates were excellent (>90%) and eligibility (77.5%) and intervention adherence were satisfactory (69% for the psychosocial support sessions). Qualitative findings revealed that participants shared positive feelings regarding their participation in the programme. The valuable interactions with group peers and health psychologists during the support sessions, the perception of the adequacy and coherence of the programme's contents and materials and the participants' confidence in using the platform developed to deliver the intervention were some of the aspects highlighted as facilitators of intervention acceptability. Additionally, people on haemodialysis and caregivers reported that participation in the programme brought several educational and emotional benefits (e.g., additional disease-related knowledge, improved communication and coping skills, greater confidence in managing dialysis complications or caregiving demands) that helped increase their self-management skills and psychosocial adjustment to the demands of kidney failure and renal therapies.

CONCLUSIONS

The results suggested that the 'Connected We St@nd' programme is likely to be feasible and acceptable for adults on haemodialysis and family caregivers, thus representing a promising resource for the future of interdisciplinary renal rehabilitation. Suggestions were made to fine-tune the intervention design to proceed with a large-scale trial.

The effectiveness of self-guided interventions in adults with depressive symptoms: a systematic review and meta-analysis

BACKGROUND

Despite promising scalability and accessibility, evidence on the efficacy of self-guided interventions for adult depression is inconclusive. This study investigated their effectiveness and acceptability, considering diverse delivery formats and support levels.

METHODS

We systematically searched PubMed, PsycINFO, Embase, and Cochrane Library until 1st January 2024. Included were randomised controlled trials comparing self-guided interventions with a control condition for adult depression. Two independent researchers extracted data. Effect sizes were pooled using random-effects models, with post-intervention depressive severity compared with control conditions as the primary outcome. Study validity was evaluated using Cochrane Risk of Bias 2.0. This study was pre-registered with OSF (https://osf.io/rd43v).

FINDINGS

We identified 92 studies (111 interventions vs. control comparisons) with 16,706 participants (mean age: 18.78-74.41 years). Compared to controls, self-guided interventions were moderately effective at post-assessment (g = 0.53, 95% CI: 0.45-0.61; I2 = 79.17%) and six to twelve months post-randomisation follow-up (g = 0.32, 95% CI: 0.16-0.48; I2 = 79.19%). Trials with initial human screening (g = 0.59) and interventions delivered in computer programs (g = 1.04) had the significantly largest effect sizes. No differences in treatment effects were observed across support levels, therapy types, commercial availability, or the presence of online discussion forums. Self-guided interventions were less acceptable than control conditions (RR = 0.92, p < 0.001). Most studies showed a moderate to high risk of bias (n = 80).

INTERPRETATION

Existing trials on self-guided interventions are at high risk of bias, potentially overestimating treatment effects. Despite lower acceptability compared to controls, self-guided interventions are moderately effective in treating adult depression, regardless of support levels and online discussion features.

FUNDING

None.

Telephone support vs. self-guidance in an Internet-based self-administered psychological program for the treatment of depression: Protocol for a hybrid type 1 effectiveness-implementation randomized controlled trial

Background

Depression is already the leading psychological disability around the world, impairing daily life, well-being, and social functioning and leading to personal and social costs. Despite the effectiveness of Evidence-Based Psychological Practices (EBPP), a significant percentage of depressive individuals remain untreated, especially in Primary Care (PC) settings in Spain. There are numerous barriers that limit access to EBPPs, including high costs, professional training, and adherence problems. Information and Communication Technologies (ICTs) offer a cost-effective way to disseminate and scale EBPPs to address these barriers. The iCBT program Smiling is Fun has been demonstrated to be a cost-effective treatment for depression in various Randomized Control Trials. However, adherence and implementation problems in real-world settings need to be addressed. Implementation research can help evaluate these challenges by identifying facilitators and barriers to the implementation process in PC. In this regard, including human support has been pointed out as a possible key factor in addressing the population's mental health needs and promoting treatment adherence.

Objective

The current study aims to examine the effectiveness, adherence rates, and implementation process of Smiling is Fun to address depression in a PC setting considering the influence of telephone support vs no support.

Methods

The proposed research is a Hybrid Effectiveness-Implementation Type I study, with a two-armed randomized controlled design, which will test a clinical intervention for major depressive disorder while gathering information on its implementation in a real-world setting. The study will include adult patients with mild to moderate symptoms of depression. Participants will be randomly assigned to one of two groups: self-applied psychotherapy or self-applied psychotherapy with psychotherapeutic telephone support. The trial will recruit 110 patient participants, with a loss-to-follow-up rate of 30 %.

Discussion

A study protocol for a hybrid effectiveness-implementation study is presented with the aim to assess the implementation of Smiling is Fun for the treatment of depression in PC. The study evaluates the influence of telephone support during a self-administered intervention compared to unguided self-administration. The main goal is to address the barriers and facilitators of the implementation process and to promote treatment adherence. Ultimately, the results of the study could help in the uptake of sustainable resources so that the population could gain better access to psychological interventions in mental health services.

Registration

ClinicalTrials.gov; NCT06230237.

How people with persistent pain experience in-person physiotherapy blended with biopsychosocial digital health - A qualitative study on participants' experiences with Back2Action

Background

A blended intervention consisting of in-person physiotherapy and psychologically-informed digital health, called Back2Action, was developed to optimise the management of people with persistent spinal pain who also have psychosocial risk factors associated with the development or maintenance of persistent pain. This study aimed to gain insights in how participants experienced this blended intervention.

Methods

A qualitative study using semi-structured interviews was conducted. Eleven people with persistent non-specific spinal pain who received the blended intervention within a randomised clinical trial were included. All interviews were recorded, transcribed verbatim and analysed independently by two researchers. Data were analysed using a thematic analysis.

Results

The analysis identified four themes: (1) Experiencing a better understanding of the relationship between own physical and mental health; (2) Importance of the physiotherapist's active involvement in biopsychosocial blended care, which describes the crucial role of physiotherapists in supporting participants in this; (3) Appreciation of digital health, to better understand persistent pain and make meaningful lifestyle changes; and (4) Trials and triumphs, revealing gains such as better coping, but also challenges with implementation of changes into long-term routines.

Conclusion

Participants of the blended intervention experienced positive changes in thoughts and behaviours, which highlights the feasibility and acceptability of the blended intervention as a more holistic treatment within pain management. The differences in personal preferences for receiving psychologically-informed digital health poses challenges for implementation of blended biopsychosocial care in evidence-based practice.

[How can the potential of internet- and mobile-based interventions be used in the treatment of depression? Findings from a qualitative survey among German psychotherapists]

INTRODUCTION AND OBJECTIVES

Internet and mobile-based interventions (IMIs) can reduce the unmet need for treatment of people with depression. The service providers as key actors in the healthcare market play an essential role in implementation. Therefore, the barriers, drivers and expectations from the perspective of psychotherapists were examined.

METHODS

In the Nuremberg area, n=15 psychotherapists were interviewed using a semi-structured guideline. The data were then evaluated according to the principles of Grounded Theory.

RESULTS

Primarily, optimizing patient benefits and bridging waiting times and aftercare were seen as advantages. Challenges exist in relation to insufficient information and communication channels between those involved in the healthcare market and the resulting lack of therapists' experiences with IMIs.

DISCUSSION

In addition to the drivers and barriers, different fields of action must be taken into account in order to increase the implementation of IMIs in the care of people with depression; these include the way that IMIs are integrated into the treatment process, the conception of IMIs and the relationships on the healthcare market. The decisive factor here is to increase cooperation between all those involved in the healthcare market.

CONCLUSION

The barriers identified are mainly due to insufficient information and communication channels within the healthcare market. They provide helpful guidance for understanding how the increased implementation of IMIs into the care process in the treatment of depression can succeed.

Long-term effects and predictors of change of internet-delivered cognitive behavioural therapy on cardiac anxiety in patients with non-cardiac chest pain: a randomized controlled trial

BACKGROUND

Approximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain.

AIMS

To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress.

METHODS

A longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program (n = 54) in patients with NCCP, compared to psychoeducation (n = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety.

RESULTS

A total of 85% (n = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life (p = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up.

CONCLUSIONS

Cardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.

Therapist-supported digital mental health intervention for depressive symptoms: A randomized clinical trial

Depression is a chronic and debilitating mental disorder. Despite the existence of several evidence-based treatments, many individuals suffering from depression face myriad structural barriers to accessing timely care which may be alleviated by digital mental health interventions (DMHI). Accordingly, this randomized clinical trial (ClinicalTrials.gov: NCT04738084) investigated the efficacy of a newer version of the therapist-supported and guided DMHI, the Meru Health Program (MHP), which was recently enhanced with heart rate variability biofeedback and lengthened from 8- to 12-weeks duration, among people with elevated depression symptoms (N = 100, mean age 37). Recruited participants were randomized to the MHP (n = 54) or a waitlist control (n = 46) condition for 12 weeks. The MHP group had greater decreases in depression symptoms compared to the waitlist control (d = -0.8). A larger proportion of participants in the MHP group reported a minimal clinically important difference (MCID) in depression symptoms than participants in the waitlist control group (39.1 % vs. 9.8 %, χ2(1) = 9.90, p = .002). Similar effects were demonstrated for anxiety symptoms, quality of life, insomnia, and resilience. The results confirm the utility of the enhanced MHP in reducing depression symptoms and associated health burdens.

Omega-3 Fatty Acids for Depression in the Elderly and Patients with Dementia: A Systematic Review and Meta-Analysis

This study aimed to evaluate the efficacy of omega-3 fatty acid supplementation interventions in improving depression in patients with dementia. To achieve this objective, randomized controlled trials (RCTs) were identified from primary electronic databases, focusing on the relationship between omega-3 fatty acids and depression in patients with dementia. The primary outcome was the impact of omega-3 fatty acids on post-intervention depression in patients with dementia, with subgroup analyses conducted based on the type of intervention (docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) combination), duration of intervention (3 months, 6 months, 12 months, ≥24 months), cognitive function (ranging from mild cognitive impairment (MCI) to severe dementia), and daily dosage (high, medium, low, applicable to both DHA and EPA). The study has been duly registered with PROSPERO (registration ID: CRD42023408744). A meta-analysis of five studies (n = 517) included in nine systematic reviews showed that omega-3 supplementation had a non-significant trend toward affecting depressive symptoms in patients with dementia (standardized mean difference (SMD): 0.147; 95% confidence interval (CI): -0.324 to 0.049; p = 0.141). Subgroup analyses revealed that DHA supplementation significantly reduced depressive symptoms (SMD: -0.247; p = 0.039). There was no significant effect for high (SMD: -0.169; 95% CI: -0.454 to 0.116; p = 0.246) or medium (SMD: -0.061; 95% CI: -0.228 to 0.105; p = 0.470) doses of EPA. However, low doses of EPA were significantly effective (SMD: -0.953; 95% CI: -1.534 to -0.373; p = 0.001), with notable improvements in patients with MCI (SMD: -0.934; p < 0.001). The study concludes that omega-3 fatty acids, particularly through DHA supplementation, may alleviate depressive symptoms in patients with MCI. Given the limited sample size, further long-term RCTs are recommended to better understand the efficacy and optimal management of omega-3 supplementation in this population using different dosages.

Barriers to and facilitators of user engagement with web-based mental health interventions in young people: a systematic review

Many young people (YP) are diagnosed with mental illnesses and require support. Web-based mental health interventions (W-MHIs) have been increasingly utilized by YP, healthcare providers, and parents due to reasons including convenience and anonymity. W-MHIs are effective in improving mental health in YP. However, real-world engagement with W-MHIs remains low. Therefore, understanding barriers/facilitators of user engagement with W-MHIs is necessary to promote W-MHIs and help users gain optimal benefits through higher engagement. This review aims to identify barriers/facilitators of user engagement with W-MHIs in YP aged 10-24 years. A systematic search of five databases for English language, peer-reviewed publications was conducted between January 2010 and February 2023. Studies examining factors influencing user engagement with W-MHIs, described as barriers or facilitators, were included. Study quality was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis was performed. Of 4088 articles identified, 69 studies were included. Barriers/facilitators were reported by young people (63 studies), providers (17 studies), and parents/caregivers (8 studies). YP perceived that usefulness and connectedness were the most common facilitators, whereas low-perceived need was the most reported barrier. Both providers and parents reported that perceived usefulness for YP was the most common facilitator, whereas concerns about program effectiveness and privacy were noted as barriers. This review found that program- and individual-related factors were important determinants of engagement with W-MHIs. This review provides guidance on the future design and development of new interventions, narrowing the gap between existing W-MHIs and unmet needs of users.

Attention Training Improves Executive Functions and Ameliorates Behavioral Symptoms in Children with Attention-Deficit Hyperactivity Disorder: Implication of Tele-Cognitive-Rehabilitation in the Era of Coronavirus Disease

Background: Children with attention-deficit hyperactivity disorder (ADHD) struggle with impaired attention, leading to impaired executive function and behavioral symptoms. In this study, we aimed to evaluate the effect of attention training on executive functions and behavioral symptoms in children with ADHD, in a tele-cognitive-rehabilitation setting. Methods: Thirty children (mean age: 9.93 ± 1.68 years, 21 boys) with ADHD were randomly assigned to 2 equal groups of attention training and active control group. Attentive Rehabilitation and Improvement of Attention (ARIA) and a class of storytelling were used for intervention in two groups, in an online platform. Continuous performance test, one-back test, Wisconsin card sorting test (WCST), Conner's parent rating scale, and behavioral rating inventory of executive function (BRIEF) were used for assessment in three-baseline, postintervention, and follow-up sessions. Repeated measures analysis of variances were used for analysis. Results: ARIA leads to significant improvement in omission error (P < 0.001), commission error (P = 0.006), and response time (P = 0.005) of continuous performance test, cluster (P = 0.001), but not preservation error (P = 0.110) of WCST, accuracy of NBT (P = 0.004) and the score of Conner's parent rating scale (P < 0.001) and BRIEF (P < 0.001). These results indicate improved attention and executive functions, amelioration of ADHD symptoms, and improved behavioral performance. Conclusion: This study suggests that attention can be trained through tele-cognitive rehabilitation using a remediation program in children with ADHD. The effectiveness of this training can be confirmed by examining the transfer of training effects to other untrained cognitive domains, executive functions, symptoms of ADHD, and behavioral performance.

Longitudinal outcomes of a therapist-supported digital mental health intervention for depression and anxiety symptoms: A retrospective cohort study

PURPOSE

This study examined treatment outcomes (depression and anxiety symptoms) up to 24 months after completion of a therapist-supported digital mental health intervention (DMHI).

METHODS

The sample consisted of 380 participants who participated in an eight-week DMHI from February 6, 2017 to May 20, 2019. Participants reported depression and anxiety symptoms at eight timepoints from baseline to 24 months. Mixed-effects modelling was used to investigate symptom changes over time. The proportion of participants meeting criteria for treatment response, clinically significant change, and remission of depression and anxiety symptoms were calculated, including proportions demonstrating each outcome sustained up to each timepoint.

RESULTS

Multivariate analyses yielded statistically significant reductions in depression (β = -5.40) and anxiety (β = -3.31) symptoms from baseline to end of treatment (8 weeks). Symptom levels remained significantly reduced from baseline through 24 months. The proportion of participants meeting criteria for clinical treatment outcomes remained constant over 24 months, although there were linear decreases in the proportions experiencing sustained clinical outcomes.

CONCLUSIONS

Treatment gains were made for depression and anxiety symptoms at the end of treatment and up to 24 months. Future studies should determine the feasibility of integrating post-treatment programmes into DMHIs to address symptom deterioration.

Guided versus non-guided digital psychological interventions for cancer patients: A systematic review and meta-analysis of engagement and efficacy

OBJECTIVE

To evaluate engagement with and efficacy of guided versus non-guided digital interventions targeting psychological symptoms of cancer via a systematic review of current evidence.

METHODS

PubMed, Scopus, PsychINFO, MEDLINE, and CINAHL databases were searched. Eligible publications were randomised controlled trials of guided or non-guided digital psychological interventions used in cancer settings reporting intervention efficacy and/or engagement. Study methodological quality was assessed using the Cochrane risk of bias (RoB) tool. Random effects meta-analyses were performed on outcomes with sufficient data, with sub-group analyses of intervention type and follow-up period.

RESULTS

Forty-three studies were included. Studies varied by level of guidance, type of technology used, duration, and outcomes assessed. Most studies had a high overall RoB. Meta-analysis indicated that guided interventions significantly reduced distress, anxiety, and fatigue, while non-guided did not. For depression and quality of life, both guided and non-guided interventions produced significant improvements. Guided interventions reported higher levels of intervention engagement than non-guided.

CONCLUSIONS

Guided digital psychological interventions were likely to be more effective than non-guided ones for cancer patients, particularly in reducing distress, anxiety, and fatigue. Whilst both types were found to improve depression and life quality, guided interventions were associated with higher patient engagement. These findings suggest digital interventions could supplement traditional cancer care, warranting further research concerning long-term effects and cost-efficiency.

"Therapy without a therapist?" The experiences of adolescents and their parents of online behavioural activation for depression with and without therapist support

Behavioural Activation (BA) is an established treatment for adults with depression, and research on BA for adolescents is promising. However, there is a knowledge gap in terms of the experiences of adolescents and their parents BA for depression delivered online. Furthermore, there have been no previous studies conducted on the experiences of respondents with regard to the role of the therapist in online treatment. Therefore, the primary aim of this study is to explore the experiences of online BA among adolescents with depression and how their parents experience supporting their adolescent through treatment. Second, the experiences of having online therapy with or without a therapist were explored. Semi-structured interviews were conducted with eight adolescents and nine parents (n = 17) who completed guided or self-guided online BA. Reflexive thematic analysis was used to identify aspects of the experience of treatment that were important to adolescents and their parents. Two main themes were generated: (1) opportunities or barriers to engaging in treatment and (2) parental involvement is valued and welcomed. This study contributes valuable information regarding user experiences of BA treatment, the importance of therapist support and parental involvement in treating adolescents with depression.Trial registration number: ClinicalTrials.gov Identifier NCT04117789, Date of registration: 07 October 2019.

From research to routine care: A historical review of internet-based cognitive behavioral therapy for adult mental health problems in Sweden

This narrative historical review examines the development of internet-based cognitive behavioral therapy (ICBT) in Sweden, describing its progression within both academic and routine care settings. The review encompasses key publications, significant scientific findings, and contextual factors in real-world settings. Over 25 years ago, Sweden emerged as a pioneering force in internet-delivered treatment research for mental health. Since then, Swedish universities, in collaboration with research partners, have produced substantial research demonstrating the efficacy of ICBT across various psychological problems, including social anxiety disorder, panic disorder, generalized anxiety disorder, and depression. Although research conducted in clinical settings has been less frequent than in academic contexts, it has confirmed the effectiveness of therapist-supported ICBT programs for mild-to-moderate mental health problems in routine care. Early on, ICBT was provided as an option for patients at both the primary care level and in specialized clinics, using treatment programs developed by both public and private providers. The development of a national platform for delivering internet-based treatment and the use of procurement in selecting ICBT programs and providers are factors that have shaped the current routine care landscape. However, gaps persist in understanding how to optimize the integration of digital treatment in routine care, warranting further research and the use of specific implementation frameworks and outcomes. This historical perspective on the research and delivery of ICBT in Sweden over two decades offers insights for the international community into the development and broad dissemination of a specific digital mental health intervention within a national context.

Efficacy of an Electronic Cognitive Behavioral Therapy Program Delivered via the Online Psychotherapy Tool for Depression and Anxiety Related to the COVID-19 Pandemic: Pre-Post Pilot Study

BACKGROUND

Lockdowns and social distancing resulting from the COVID-19 pandemic have worsened the population's mental health and made it more difficult for individuals to receive care. Electronic cognitive behavioral therapy (e-CBT) is a cost-effective and evidence-based treatment for anxiety and depression and can be accessed remotely.

OBJECTIVE

The objective of the study was to investigate the efficacy of online psychotherapy tailored to depression and anxiety symptoms during the pandemic.

METHODS

The pilot study used a pre-post design to evaluate the efficacy of a 9-week e-CBT program designed for individuals with depression and anxiety affected by the pandemic. Participants were adults (N=59) diagnosed with major depressive disorder and generalized anxiety disorder, whose mental health symptoms initiated or worsened during the COVID-19 pandemic. The online psychotherapy program focused on teaching coping, mindfulness, and problem-solving skills. Symptoms of anxiety and depression, resilience, and quality of life were assessed.

RESULTS

Participants demonstrated significant improvements in symptoms of anxiety (P=.02) and depression (P=.03) after the intervention. Similar trends were observed in the intention-to-treat analysis. No significant differences were observed in resilience and quality-of-life measures. The sample comprised mostly females, making it challenging to discern the benefits of the intervention in males. Although a pre-post design is less rigorous than a controlled trial, this design was selected to observe changes in scores during a critical period.

CONCLUSIONS

e-CBT for COVID-19 is an effective and accessible treatment option. Improvements in clinical symptoms of anxiety and depression can be observed in individuals whose mental health is affected by the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/study/NCT04476667.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24913.

Comparing the efficacy of electronic cognitive behavioral therapy to medication and combination therapy for generalized anxiety disorder: a quasi-experimental clinical trial

Background

Generalized anxiety disorder (GAD) is a debilitating mental health disorder with first-line treatments include cognitive behavioral therapy (CBT) and pharmacotherapy. CBT is costly, time-consuming, and inaccessible. Electronic delivery (e-CBT) is a promising solution to address these barriers. However, due to the novelty of this intervention, more research testing the e-CBT efficacy independently and in conjunction with other treatments is needed.

Objective

This study investigated the efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD.

Methods

This study employed a quasi-experimental design where patients selected their preferred treatment modality. Patients with GAD were enrolled in either e-CBT, medication, or combination arms. The 12-week e-CBT program was delivered through a digital platform. The medications followed clinical guidelines. The efficacy of each arm was evaluated using questionnaires measuring depression, anxiety, and stress severity, as well as quality of life.

Results

There were no significant differences between arms (N e-CBT = 41; N Medication = 41; N Combination = 33) in the number of weeks completed or baseline scores. All arms showed improvements in anxiety scores after treatment. The medication and combination arms improved depression scores. The e-CBT and Combination arms improved quality of life, and the combination arm improved stress scores. There were no differences between the groups in depression, anxiety, or stress scores post-treatment. However, the combination arm had a significantly larger improvement in quality of life. Gender and treatment arm were not predictors of dropout, whereas younger age was.

Conclusion

Incorporating e-CBT on its own or in combination with pharmaceutical interventions is a viable option for treating GAD. Treating GAD with e-CBT or medication appears to offer significant improvements in symptoms, with no meaningful difference between the two. Combining the treatments also offer significant improvements, while not necessarily superior to either independently. The findings suggest that all options are viable. Taking the patient's preferred treatment route based on their lifestyle, personality, and beliefs into account when deciding on treatment should be a priority for care providers.

Comparison of internet-based and face-to-face cognitive behavioral therapy for obsessive-compulsive disorder: A systematic review and network meta-analysis

Cognitive behavioral therapy (CBT) is widely recognized as an effective treatment for obsessive-compulsive disorder (OCD). However, few patients are able to receive CBT. Internet-based CBT (ICBT) may be able to overcome this problem. In this study, we aimed to compare the efficacy of CBT, therapist-guided ICBT (TG-ICBT), unguided ICBT (UG-ICBT), and none therapist-guided ICBT (NTG-ICBT) by a network meta-analysis. The primary outcome was the mean change in OCD severity measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The secondary outcomes included the severity of depressive symptoms, side effects, and cost-effectiveness. A total of 25 trials with 1642 participants were included. We found that the efficacy of CBT was superior to that of TG-ICBT. The mean improvement in Y-BOCS/CY-BOCS scores was higher in CBT group than in UG-ICBT group, but this difference was not statistically significant. The efficacy did not differ significantly between TG-ICBT and UG-ICBT. CBT, TG-ICBT, and UG-ICBT were all more effective than the psychological placebo, waiting list, and pill placebo. In terms of efficacy, CBT combined with drug therapy was better than CBT, TG-ICBT, and UG-ICBT. Sensitivity analyses supported these findings. Based on the current evidence, we recommend TG-ICBT when CBT is not available. However, it is undeniable that UG-ICBT also has the potential to be an effective alternative to CBT. More evidence is needed to support this possibility.

A systematic review and meta-analysis of Internet-based self-help interventions for mental health among adolescents and college students

Purpose

This meta-analysis aims to evaluate the impact of Internet-based self-help interventions on the mental health of adolescents and college students.

Methods

We conducted a systematic review of randomized controlled trials (RCTs) that investigated Internet-based self-help interventions aiming to mitigate mental health symptoms such as anxiety and depression, as well as managing high levels of stress, among adolescents and college students. Our search spanned databases including Web of Science, PubMed, Cochrane Library, and Embase, up until November 1st, 2022. It is essential to emphasize that our focus was the evaluation of symptoms (continuous outcomes), rather than the diagnosis of specific mental disorders. The meta-analysis was performed using the R version 4.3.1. The effect size measure was the standardized mean difference (SMD), and random-effects models were used to pool data from eligible RCTs. Subgroup analyses were carried out to examine variations in intervention effects based on factors such as sample type, intervention modality, guidance type, and intervention duration.

Results

The meta-analysis was based on 25 comparisons involving a total of 4480 participants. In comparison to the control group (n = 2125), participants receiving interventions (n = 2355) reported significant reductions in symptoms of anxiety, depression, and stress, along with a significant improvement in quality of life. Specifically, for depression, we observed moderate intervention effects (SMD = -0.42, 95 % CI: -0.56, -0.27), and a similar pattern was seen for quality of life (SMD = 0.36, 95%CI: 0.22, 0.49). Small intervention effects were found for anxiety (SMD = -0.35, 95 % CI [-0.48, -0.22]) and stress (SMD = -0.35, 95 % CI [-0.51, -0.20]). Given significant heterogeneity, subgroup analyses were conducted for anxiety and depression, considering factors such as sample type, intervention method, and intervention duration. Notably, college students experienced more significant benefits in both anxiety and depression alleviation compared to adolescents. Longer interventions (>8 weeks) were particularly effective in reducing anxiety and depression. Additionally, third-wave cognitive-behavioral therapy (CBT) showed pronounced intervention effects in both outcome measures, while the presence of guidance did not notably influence results.

Conclusion

This meta-analysis underscores the positive impact of Internet-based self-help programs in alleviating the symptoms of psychological disorders among adolescents and college students. However, it is crucial to acknowledge that the available evidence exhibits inconsistencies and limitations. Therefore, further research utilizing rigorous methodologies is necessary to verify and broaden the findings of this meta-analysis.

Exploring reasons for usage discontinuation in an internet-delivered stress recovery intervention: A qualitative study

Internet-delivered cognitive behavioral therapy (ICBT) interventions can be as effective as traditional face-to-face therapy for various mental health conditions. However, a significant challenge these online interventions face is the high rate of people who start but then stop using the program. This early discontinuation can be seen as incomplete treatment and can reduce the potential benefits for users. By exploring why people stop using ICBT programs, we can better understand how to address this problem. This study aimed to examine the experiences of healthcare workers who had stopped using a therapist-guided internet-delivered stress recovery program to gain deeper insights into usage attrition. We conducted semi-structured interviews with twelve participants who were female healthcare workers ranging in age from 24 to 68 years (M = 44.67, SD = 11.80). Telephone interviews were conducted and the data were transcribed and analyzed using thematic analysis. Qualitative data analysis revealed that most participants had multiple reasons for discontinuing the program. They identified both barriers and facilitators to using the program, which could be categorized as either personal or program related. Personal aspects included life circumstances, personal characteristics, and psychological responses to the program. Program-related aspects encompassed technical factors, program content, and the level of support provided. The findings of this study can enhance our understanding of why people stop using guided internet-delivered programs. We discuss the practical and research implications, with the ultimate aim of improving the design and efficacy of internet interventions.

The effects of psychosocial and behavioral interventions on depressive and anxiety symptoms during the COVID-19 pandemic: a systematic review and meta-analysis

Psychosocial and behavioral interventions have been shown to significantly reduce depressive and anxiety symptoms in different populations. Recent evidence suggests that the mental health of the general population has deteriorated significantly since the start of Coronavirus Disease 2019 (COVID-19) pandemic. We conducted a systematic review and meta-analysis of studies on the therapeutic effects of psychosocial and behavioral interventions on depression and anxiety during the COVID-19 pandemic. We systematically searched six electronic databases between December 2019 and February 2022 including PubMed, PsycINFO, Scopus, Web of Science, CNKI, and Wanfang Data. We included randomized clinical trials of psychosocial and behavioral interventions in individuals with depressive or anxiety symptoms during the COVID-19 outbreak compared to various control conditions. A total of 35 eligible studies with 5457 participants were included. The meta-analysis results showed that psychosocial and behavioral interventions had statistically significant moderate effects on depression [SMD =  - 0.73, 95% CI (- 1.01, - 0.45), I2 = 90%] and large effects on anxiety [SMD =  - 0.90, 95% CI (- 1.19, - 0.60), I2 = 92%], especially in the general population and COVID-19 survivors. Exercise and cognitive behavioral therapy were found to be the most effective treatments with moderate-to-large effect size for depression and anxiety during the outbreak of COVID-19. We also found the internet-based approach could also achieve almost equally significant effects on depression and anxiety compared with face-to-face traditional approach. Our findings suggest that cognitive behavioral therapy and physical exercise intervention are significantly effective for depression and anxiety related to the COVID-19 pandemic regardless of the delivery modes, and gender differences should be taken into consideration for better implementation of interventions in clinical and community practice.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Longitudinal Patterns of Engagement and Clinical Outcomes: Results From a Therapist-Supported Digital Mental Health Intervention

OBJECTIVE

Digital mental health interventions (DMHIs) are an effective treatment modality for common mental disorders like depression and anxiety; however, the role of intervention engagement as a longitudinal "dosing" factor is poorly understood in relation to clinical outcomes.

METHODS

We studied 4978 participants in a 12-week therapist-supported DMHI (June 2020-December 2021), applying a longitudinal agglomerative hierarchical cluster analysis to the number of days per week of intervention engagement. The proportion of people demonstrating remission in depression and anxiety symptoms during the intervention was calculated for each cluster. Multivariable logistic regression models were fit to examine associations between the engagement clusters and symptom remission, adjusting for demographic and clinical characteristics.

RESULTS

Based on clinical interpretability and stopping rules, four clusters were derived from the hierarchical cluster analysis (in descending order): a) sustained high engagers (45.0%), b) late disengagers (24.1%), c) early disengagers (22.5%), and d) immediate disengagers (8.4%). Bivariate and multivariate analyses supported a dose-response relationship between engagement and depression symptom remission, whereas the pattern was partially evident for anxiety symptom remission. In multivariable logistic regression models, older age groups, male participants, and Asians had increased odds of achieving depression and anxiety symptom remission, whereas higher odds of anxiety symptom remission were observed among gender-expansive individuals.

CONCLUSIONS

Segmentation based on the frequency of engagement performs well in discerning timing of intervention disengagement and a dose-response relationship with clinical outcomes. The findings among the demographic subpopulations indicate that therapist-supported DMHIs may be effective in addressing mental health problems among patients who disproportionately experience stigma and structural barriers to care. Machine learning models can enable precision care by delineating how heterogeneous patterns of engagement over time relate to clinical outcomes. This empirical identification may help clinicians personalize and optimize interventions to prevent premature disengagement.

The role of therapist support on the efficacy of an internet-delivered stress recovery intervention for healthcare workers: a randomized control trial

Internet-delivered CBT interventions effectively improve different aspects of mental health, although the therapist's role remains unclear. The aim of this trial was to evaluate the efficacy of a therapist-supported 6-week internet-delivered intervention in improving stress recovery among healthcare workers compared to a group with optional therapist support. A total of 196 participants were recruited and randomly allocated to regular therapists' support or optional therapists' support groups. The primary outcome measure was the Recovery Experiences Questionnaire (REQ), developed to assess four components of stress recovery: psychological detachment, relaxation, mastery, and control. Secondary outcomes measured perceived stress (PSS-10), anxiety (GAD-7), depression (PHQ-9), and psychological well-being (WHO-5). All four stress recovery skills improved significantly after participating in the intervention at a 3-month follow-up, with small to medium effects (0.27-0.65) in both groups. At follow-up, we also found a significant reduction in perceived stress, depression, and anxiety in both groups, as well as an improvement in psychological well-being. The results indicate that ICBT can be effective in improving stress recovery skills among healthcare workers with optional support from the therapist, provided at the participants' request. This RCT suggests that optional therapist support could meet participants' needs and reduce resources needed in routine care.

The effectiveness of cognitive-behavioral therapy for heart failure patients: a narrative review

Heart failure (HF) remains a major cause of morbidity, mortality and healthcare costs, despite available treatments. Psychological issues such as depression, anxiety and poor self-care are prevalent in HF patients. Such issues adversely affect patients' daily lives and increase hospitalization and mortality rates; therefore, effective approaches to address these are needed. Cognitive-behavioral therapy (CBT) has been proposed as potentially useful for psychological comorbidities in HF patients, but its efficacy is not well-established. This narrative review aimed to summarize the evidence on the effectiveness of CBT for HF patients. A search was conducted using PubMed and Google Scholar for randomized controlled trials (RCTs) on CBT for HF patients. Ten studies (nine RCTs and one case study) were included in the review. CBT was found to be an effective intervention for managing depression, anxiety, low quality of life, and impaired social and physical functioning in HF patients. The results suggest that CBT can improve psychological well-being and enhance the benefits of rehabilitation programs. Face-to-face CBT appears to be superior to conventional therapy and can be implemented in cardiac rehabilitation settings. Further research is needed to evaluate the efficacy of internet-based CBT for cardiac patients and identify factors that promote treatment adherence.

Trajectories of depression symptoms in a therapist-supported digital mental health intervention: a repeated measures latent profile analysis

PURPOSE

Major depression affects 10% of the US adult population annually, contributing to significant burden and impairment. Research indicates treatment response is a non-linear process characterized by combinations of gradual changes and abrupt shifts in depression symptoms, although less is known about differential trajectories of depression symptoms in therapist-supported digital mental health interventions (DMHI).

METHODS

Repeated measures latent profile analysis was used to empirically identify differential trajectories based upon biweekly depression scores on the Patient Health Questionnaire-9 (PHQ-9) among patients engaging in a therapist-supported DMHI from January 2020 to July 2021. Multivariate associations between symptom trajectories with sociodemographics and clinical characteristics were examined with multinomial logistic regression. Minimal clinically important differences (MCID) were defined as a five-point change on the PHQ-9 from baseline to week 12.

RESULTS

The final sample included 2192 patients aged 18 to 82 (mean = 39.1). Four distinct trajectories emerged that differed by symptom severity and trajectory of depression symptoms over 12 weeks. All trajectories demonstrated reductions in symptoms. Despite meeting MCID criteria, evidence of treatment resistance was found among the trajectory with the highest symptom severity. Chronicity of major depressive episodes and lifetime trauma exposures were ubiquitous across the trajectories in a multinomial logistic regression model.

CONCLUSIONS

These data indicate that changes in depression symptoms during DMHI are heterogenous and non-linear, suggesting a need for precision care strategies to address treatment resistance and increase engagement. Future efforts should examine the effectiveness of trauma-informed treatment modules for DMHIs as well as protocols for continuation treatment and relapse prevention.

Validation of the Attitudes Towards Psychological Online Interventions Questionnaire Among Black Americans: Cross-cultural Confirmatory Factor Analysis

BACKGROUND

Acceptability of digital mental health interventions is a significant predictor of treatment-seeking behavior and engagement. However, acceptability has been conceptualized and operationalized in various ways, which decreases measurement precision and leads to heterogeneous conclusions about acceptability. Standardized self-report measures of acceptability have been developed, which have the potential to ameliorate these problems, but none have demonstrated evidence for validation among Black communities, which limits our understanding of attitudes toward these interventions among racially minoritized groups with well-documented barriers to mental health treatment.

OBJECTIVE

This study aims to examine the psychometric validity and reliability of one of the first and most widely used measures of acceptability, the Attitudes Towards Psychological Online Interventions Questionnaire, among a Black American sample.

METHODS

Participants (N=254) were recruited from a large southeastern university and the surrounding metropolitan area and completed the self-report measure via a web-based survey. A confirmatory factor analysis using mean and variance adjusted weighted least squares estimation was conducted to examine the validity of the underlying hierarchical 4-factor structure proposed by the original authors of the scale. An alternative, hierarchical 2-factor structure model and bifactor model were examined for comparative fit.

RESULTS

The findings indicated that the bifactor model demonstrated a superior fit (comparative fit index=0.96, Tucker-Lewis index=0.94, standardized root mean squared residual=0.03, and root mean square error of approximation=0.09) compared with both 2- and 4-factor hierarchical structure models.

CONCLUSIONS

The findings suggest that, within a Black American sample, there may be greater utility in interpreting the Attitudes Towards Psychological Online Interventions Questionnaire subscales as attitudinal constructs that are distinct from the global acceptability factor. The theoretical and practical implications for culturally responsive measurements were explored.

Development and pilot testing of internet-delivered, family-based cognitive behavioral therapy for anxiety and obsessive-compulsive disorders in autistic youth

Cognitive behavioral therapy adapted for autistic youth with anxiety and/or OCD has a strong evidence base, but few have access. A 12-week family-based, Internet-delivered cognitive behavioral therapy (iCBT) program for 7-15 year-old autistic youth with anxiety and/or OCD was developed as a potential method to address this problem. Quantitative and qualitative feedback from stakeholders (parents, youth, clinicians) was gathered on an initial draft of content before conducting a pilot trial. This feedback suggested high quality, engagement, usability, and informativeness of the material. Suggestions were incorporated into the treatment program that was tested in a pilot trial. Eight families were randomized to the iCBT program with either 1) weekly email support or 2) weekly email support plus biweekly telehealth check-ins, and seven of these families completed pre- and post-treatment assessments. An average reduction of 39% in anxiety severity was found, with six of the seven being classified as responders. Preliminary evidence suggests that family-based iCBT is an acceptable and promising treatment for autistic youth with anxiety and/or obsessive-compulsive disorders that should be further modified and tested in future work.

Long-term psychodynamic psychotherapy in a face-to-face versus videoconferencing setting: A single case study

OBJECTIVE

Due to the coronavirus pandemic and crisis, psychotherapists around the world were forced to switch to video- or tele-based treatments overnight. To date, only a few studies on the effectiveness of video-based psychodynamic psychotherapy via the Internet exist. Therefore, the goal of the present study was to examine symptom improvement, therapeutic relationship, nonverbal synchrony processes, and intersession processes within a systematic single case design and compare face-to-face to video-based approaches in long-term psychodynamic-oriented psychotherapy.

METHODS

We examined 85 sessions of a client with major depression whose psychodynamic psychotherapy changed from a face-to-face setting to a video-based setting. Video recordings were analyzed using motion energy analysis, and nonverbal synchrony was computed using a surrogate synchrony approach. Time series analyses were performed to analyze changes in symptom severity, therapeutic relationship, and intersession processes.

RESULTS

The results showed that symptom severity improved descriptively, but not significantly, across the entire course of psychotherapy. There were significant differences, however, in the therapeutic relationship, intersession experiences, and synchronous behavior between the face-to-face and video-based settings.

CONCLUSION

The results indicate that the presented methodology is well situated to investigate the question whether psychodynamic psychotherapy in video-based setting works in the sameway as in a face-to-face setting.

Study protocol for a factorial-randomized controlled trial evaluating the implementation, costs, effectiveness, and sustainment of digital therapeutics for substance use disorder in primary care (DIGITS Trial)

BACKGROUND

Experts recommend that treatment for substance use disorder (SUD) be integrated into primary care. The Digital Therapeutics for Opioids and Other SUD (DIGITS) Trial tests strategies for implementing reSET® and reSET-O®, which are prescription digital therapeutics for SUD and opioid use disorder, respectively, that include the community reinforcement approach, contingency management, and fluency training to reinforce concept mastery. This purpose of this trial is to test whether two implementation strategies improve implementation success (Aim 1) and achieve better population-level cost effectiveness (Aim 2) over a standard implementation approach.

METHODS/DESIGN

The DIGITS Trial is a hybrid type III cluster-randomized trial. It examines outcomes of implementation strategies, rather than studying clinical outcomes of a digital therapeutic. It includes 22 primary care clinics from a healthcare system in Washington State and patients with unhealthy substance use who visit clinics during an active implementation period (up to one year). Primary care clinics implemented reSET and reSET-O using a multifaceted implementation strategy previously used by clinical leaders to roll-out smartphone apps ("standard implementation" including discrete strategies such as clinician training, electronic health record tools). Clinics were randomized as 21 sites in a 2x2 factorial design to receive up to two added implementation strategies: (1) practice facilitation, and/or (2) health coaching. Outcome data are derived from electronic health records and logs of digital therapeutic usage. Aim 1's primary outcomes include reach of the digital therapeutics to patients and fidelity of patients' use of the digital therapeutics to clinical recommendations. Substance use and engagement in SUD care are additional outcomes. In Aim 2, population-level cost effectiveness analysis will inform the economic benefit of the implementation strategies compared to standard implementation. Implementation is monitored using formative evaluation, and sustainment will be studied for up to one year using qualitative and quantitative research methods.

DISCUSSION

The DIGITS Trial uses an experimental design to test whether implementation strategies increase and improve the delivery of digital therapeutics for SUDs when embedded in a large healthcare system. It will provide data on the potential benefits and cost-effectiveness of alternative implementation strategies.

CLINICALTRIALS

gov Identifier: NCT05160233 (Submitted 12/3/2021). https://clinicaltrials.gov/ct2/show/NCT05160233.

Unpacking the active ingredients of internet-based psychodynamic therapy for adolescents

Internet-based psychodynamic psychotherapy (iPDT) for adolescents has been found to be effective for treating depression, but not much is known about its active ingredients.

OBJECTIVE

To explore the techniques used in chat sessions in an iPDT program for depressed adolescents, and to investigate whether they predicted improvement in depression symptoms.

METHOD

The study uses data collected from a pilot study. The iPDT consisted of 8 modules delivered over 10 weeks that included text, video, exercises, and a weekly text-based chat session with a therapeutic support worker (TSW). The participants were 23 adolescents meeting criteria for depression. The TSWs were 9 psychology master's students. A depression inventory QIDS-A17-SR was filled weekly by the participants, and a self-rated techniques inventory (MULTI-30) was filled by the TSWs after each chat session.

RESULTS

Common factor techniques were the most widely used techniques in the chat sessions. Both common factors and psychodynamic techniques predicted improvement in depression, with psychodynamic techniques predicting improvement at the following week. CBT techniques were also used but did not predict improvement in depression.

CONCLUSION

iPDT seem to work in line with theory, where the mechanisms thought to be important for change in treatment were predictive of outcome.

Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore?

BACKGROUND

Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response.

PROCEDURES

Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response.

FINDINGS

A number of 'third wave' therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more 'personalised medicine informed' treatment strategizing for OCD.

CONCLUSIONS

There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.

"Good job!": Therapists' encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression

Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.

Feasibility of Self-Guided Online Cognitive Behavioral Therapy for University Students During COVID-19

Objective: This study aimed to test the feasibility and efficacy of a self-guided online cognitive behaviour therapy (iCBT) for university students in Hong Kong during COVID-19. Method: One group pre-post-test design with convenient sampling was adopted in this study, involving 84 university students who received a newly developed iCBT within an 8 week intervention period. The iCBT offered eight online modules for students to learn the skills of CBT at home through an online platform which was accessible any time anywhere anonymously with technical support only. Standardized assessment tools were used for outcomes assessment at the pre- and post-intervention periods. Results: Three quarters of participants completed all iCBT modules. The results of paired t-tests showed that, after completing the iCBT, participants showed reduction in anxiety, depression, and perceived stress. Conclusion: This study provides preliminary evidences to support the feasibility and efficacy of the self-guided iCBT for university students during COVID-19.

A systematic review of digital and face-to-face cognitive behavioral therapy for depression

Cognitive behavioral therapy (CBT) represents one of the major treatment options for depressive disorders besides pharmacological interventions. While newly developed digital CBT approaches hold important advantages due to higher accessibility, their relative effectiveness compared to traditional CBT remains unclear. We conducted a systematic literature search to identify all studies that conducted a CBT-based intervention (face-to-face or digital) in patients with major depression. Random-effects meta-analytic models of the standardized mean change using raw score standardization (SMCR) were computed. In 106 studies including n = 11854 patients face-to-face CBT shows superior clinical effectiveness compared to digital CBT when investigating depressive symptoms (p < 0.001, face-to-face CBT: SMCR = 1.97, 95%-CI: 1.74–2.13, digital CBT: SMCR = 1.20, 95%-CI: 1.08–1.32) and adherence (p = 0.014, face-to-face CBT: 82.4%, digital CBT: 72.9%). However, after accounting for differences between face-to-face and digital CBT studies, both approaches indicate similar effectiveness. Important variables with significant moderation effects include duration of the intervention, baseline severity, adherence and the level of human guidance in digital CBT interventions. After accounting for potential confounders our analysis indicates comparable effectiveness of face-to-face and digital CBT approaches. These findings underline the importance of moderators of clinical effects and provide a basis for the future personalization of CBT treatment in depression.

Mapping User Engagement in Digital Psychotherapy: An Integrative Engagement Model (Preprint)

BACKGROUND

Digital mental health interventions, such as 2-way and asynchronous messaging therapy, are a growing part of the mental health care treatment ecosystem, yet little is known about how users engage with these interventions over the course of their treatment journeys. User engagement, or client behaviors and therapeutic relationships that facilitate positive treatment outcomes, is a necessary condition for the effectiveness of any digital treatment. Developing a better understanding of the factors that impact user engagement can impact the overall effectiveness of digital psychotherapy. Mapping the user experience in digital therapy may be facilitated by integrating theories from several fields. Specifically, health science's Health Action Process Approach and human-computer interaction's Lived Informatics Model may be usefully synthesized with relational constructs from psychotherapy process-outcome research to identify the determinants of engagement in digital messaging therapy.

OBJECTIVE

This study aims to capture insights into digital therapy users' engagement patterns through a qualitative analysis of focus group sessions. We aimed to synthesize emergent intrapersonal and relational determinants of engagement into an integrative framework of engagement in digital therapy.

METHODS

A total of 24 focus group participants were recruited to participate in 1 of 5 synchronous focus group sessions held between October and November 2021. Participant responses were coded by 2 researchers using thematic analysis.

RESULTS

Coders identified 10 relevant constructs and 24 subconstructs that can collectively account for users' engagement and experience trajectories in the context of digital therapy. Although users' engagement trajectories in digital therapy varied widely, they were principally informed by intrapsychic factors (eg, self-efficacy and outcome expectancy), interpersonal factors (eg, the therapeutic alliance and its rupture), and external factors (eg, treatment costs and social support). These constructs were organized into a proposed Integrative Engagement Model of Digital Psychotherapy. Notably, every participant in the focus groups indicated that their ability to connect with their therapist was among the most important factors that were considered in continuing or terminating treatment.

CONCLUSIONS

Engagement in messaging therapy may be usefully approached through an interdisciplinary lens, linking constructs from health science, human-computer interaction studies, and clinical science in an integrative engagement framework. Taken together, our results suggest that users may not view the digital psychotherapy platform itself as a treatment so much as a means of gaining access to a helping provider, that is, users did not see themselves as engaging with a platform but instead viewed their experience as a healing relationship. The findings of this study suggest that a better understanding of user engagement is crucial for enhancing the effectiveness of digital mental health interventions, and future research should continue to explore the underlying factors that contribute to engagement in digital mental health interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04507360; https://clinicaltrials.gov/ct2/show/NCT04507360.

Reducing stress and anxiety in patients with myocardial infarction with non-obstructive coronary arteries or Takotsubo syndrome: A non-randomized feasibility study

BACKGROUND AND AIM

In the aftermath of a myocardial infarction with non-obstructive coronary arteries (MINOCA) or Takotsubo syndrome (TS), patients commonly express high levels of stress and anxiety. Current treatment alternatives rarely address these issues. The planned E-health Treatment of Stress and Anxiety in Stockholm Myocardial Infarction With Non-obstructive Coronaries Study (e-SMINC) aims to evaluate the effects of an internet-based intervention, building on cognitive behavioral therapy (CBT) by comparison with treatment as usual using an RCT approach. This was a small-scale single arm study designed to test the feasibility of the RCT, addressing uncertainties regarding recruitment, data collection, and intervention delivery.

METHODS

Participant recruitment and screening took place before discharge from the coronary care unit at a large Swedish hospital. Eligible patients were invited to a nine-step psychologist guided, internet-based CBT intervention. The sample size was set in advance to 10 participants completing the intervention. The recruitment and flow of participants were documented and evaluated in relation to seven pre-defined progression criteria. Self-reports of anxiety (HADS-A), stress (PSS-14), cardiac anxiety (CAQ), posttraumatic stress (IES-6) and quality of life (Rand-36), collected at screening, pre-intervention and post-intervention, were analysed descriptively and by effect sizes (Cohen's d). Individual interviews targeting participant experiences were conducted.

RESULTS

Six out of seven progression criteria yielded no concerns. Out of 49 patients with a working diagnosis of MINOCA or TS, 31 were eligible for screening, 26 consented to participate, and 14 were eligible with regard to symptoms of stress and/or anxiety. Eleven completed the pre-assessment and were given access the intervention, and 9 completed the intervention. Only the number of patients screened prior to eligibility assessment was slightly lower than expected, indicating possible concerns. Self-reports of anxiety, stress, cardiac anxiety, posttraumatic stress, and quality of life all indicated symptom reduction from pre- to post-intervention, generally showing large effect sizes (d = 0.6-2.6). The general consensus among participants was that the programme was helpful and relevant, and that the personal contact with the psychologist was highly valued. Setting aside time to complete assignments was found critical.

CONCLUSION

Conducting a full scale RCT was found feasible. Inclusion of more study sites and minor amendments to the protocol and intervention were decided to improve feasibility further.

TRIAL REGISTRATION

Clinicaltrials.govNCT04178434.

Connecting over the internet: Establishing the therapeutic alliance in an internet-based treatment for depressed adolescents

Internet-based treatments have been developed for youth mental health difficulties, with promising results. However, little is known about the features of therapeutic alliance, and how it is established and maintained, in text-based interactions between adolescents and therapists in internet-based treatments. This study uses data collected during a pilot evaluation of a psychodynamic internet-based therapy for depressed adolescents. The adolescents had instant-messaging chats with their therapists once a week, over 10 weeks. The adolescents also rated the therapeutic alliance each week, using the Session Alliance Inventory. The present study uses qualitative methods to analyse transcripts of text-based communication between the young people and their therapists. The aim is to identify and describe the key features of therapeutic alliance, and reflect upon the implications for theory and clinical practice. Analysis identified three 'values' that may underpin a strong therapeutic alliance: togetherness, agency and hope. A number of therapist techniques were also found, which seemed to create a sense of these values during text-chat sessions. These findings are discussed, alongside implications for future research.

A Pharmacy-Based eHealth Intervention Promoting Correct Use of Medication in Patients With Asthma and COPD: Nonrandomized Pre-Post Study

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) affect millions of people worldwide. While medication can control and improve disease symptoms, incorrect use of medication is a common problem. The eHealth intervention SARA (Service Apothecary Respiratory Advice) aims to improve participants' correct use of inhalation medication by providing information and as-needed tailored follow-up support by a pharmacist.

OBJECTIVE

The primary aim of this study was to investigate the effect of SARA on exacerbation rates in participants with asthma and COPD. Secondary aims were to investigate its effects in terms of adherence to maintenance medication and antimycotic treatment.

METHODS

In this nonrandomized pre-post study, medication dispensing data from 382 Dutch community pharmacies were included. Exacerbation rates were assessed with dispensed short-course oral corticosteroids. Medication adherence between new and chronic users was assessed by calculating the proportion of days covered from dispensed inhalation maintenance medication. Antimycotic treatment was investigated from dispensed oral antimycotics in participants who were also dispensed inhaled corticosteroids (ICS). Outcomes were assessed 1 year before and 1 year after implementation of SARA and were compared between SARA participants and control participants. More specifically, for exacerbation rates and medication adherence, a difference score was calculated (ie, 1 year after SARA minus 1 year before SARA) and was subsequently compared between the study groups with independent-samples t tests. For antimycotics, the relative number of participants who were dispensed antimycotics was calculated and subsequently analyzed with a mixed-effects logistic regression.

RESULTS

The study population comprised 9452 participants, of whom 2400 (25.39%) were SARA participants. The mean age of the population was 60.8 (15.0) years, and approximately two-thirds (n=5677, 60.06%) were female. The results showed an increase in mean exacerbation rates over time for both study groups (SARA: 0.05; control: 0.15). However, this increase in exacerbation rates was significantly lower for SARA participants (t₉₄₅₀=3.10, 95% CI 0.04-0.16; P=.002; Cohen d=0.06). Chronic users of inhalation medication in both study groups showed an increase in mean medication adherence over time (SARA: 6.73; control: 4.48); however, this increase was significantly higher for SARA participants (t₅₈₈₆=-2.74, 95% CI -3.86 to -0.84; P=.01; Cohen d=-0.07). Among new users of inhalation medication, results showed no significant difference in medication adherence between SARA and control participants in the year after implementation of SARA (t₁₄₃₄=-1.85, 95% CI -5.60 to 0.16; P=.06; Cohen d=-0.10). Among ICS users, no significant differences between the study groups were found over time in terms of the proportion of participants who were dispensed antimycotics (t₅₆₅₄=0.29, 95% CI -0.40 to 0.54; P=.76; Cohen d=0).

CONCLUSIONS

This study provides preliminary evidence that the SARA eHealth intervention might have the potential to decrease exacerbation rates and improve medication adherence among patients with asthma and COPD.

Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review

BACKGROUND

Smartphone app-based therapies offer clear promise for reducing the gap in available mental health care for people at risk for or people with mental illness. To this end, as smartphone ownership has become widespread, app-based therapies have become increasingly common. However, the research on app-based therapies is lagging behind. In particular, although experts suggest that human support may be critical for increasing engagement and effectiveness, we have little systematic knowledge about the role that human support plays in app-based therapy. It is critical to address these open questions to optimally design and scale these interventions.

OBJECTIVE

The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach.

METHODS

We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded.

RESULTS

Of the 2940 titles returned by the searches, 64 (2.18%) were eligible for inclusion. This review found significant heterogeneity across all of the dimensions of coaching considered as well as considerable missing information in the published articles. Moreover, few studies had qualitatively or quantitatively evaluated how the level of coaching impacts treatment engagement or outcomes. Although users tend to self-report that coaching improves their engagement and outcomes, there is limited and mixed supporting quantitative evidence at present.

CONCLUSIONS

Digital mental health is a young but rapidly expanding field with great potential to improve the reach of evidence-based care. Researchers across the reviewed articles offered numerous approaches to encouraging and guiding users. However, with the relative infancy of these treatment approaches, this review found that the field has yet to develop standards or consensus for implementing coaching protocols, let alone those for measuring and reporting on the impact. We conclude that coaching remains a significant hole in the growing digital mental health literature and lay out recommendations for future data collection, reporting, experimentation, and analysis.

Feasibility and Acceptability of Internet-based Interpersonal Psychotherapy for Stress, Anxiety, and Depression in Prenatal Women: Thematic Analysis Abstract (Preprint)

Background

Prenatal mental health is a global health concern. Despite the far-reaching impact of prenatal mental health issues, many women do not receive the psychological care they require. Women in their childbearing years are frequent users of the internet and smartphone apps. Prenatal women are prime candidates for internet-based support for mental health care.

Objective

This study aimed to examine the feasibility and acceptability of internet-based interpersonal psychotherapy (IPT) for prenatal women.

Methods

Semistructured interviews were conducted with women who had received internet-based IPT modules with guided support as a component of a randomized controlled trial evaluating the scale-up implementation of a digital mental health platform (The Healthy Outcomes of Pregnancy and Postpartum Experiences digital platform) for pregnant women. Qualitative thematic analysis was used to explore and describe women’s experiences. Data were analyzed for emerging themes, which were identified and coded.

Results

A total of 15 prenatal women were interviewed to examine their experiences and views on the feasibility and acceptability of internet-based IPT modules. Participants found the content informative and appreciated the ways in which the digital mental health platform made the IPT modules accessible to users. Participants voiced some differing requirements regarding the depth and the way information was presented and accessed on the digital mental health platform. The important areas for improvement that were identified were acknowledging greater depth and clarity of content, the need for sociability and relationships, and refinement of the digital mental health platform to a smartphone app.

Conclusions

This study provides useful evidence regarding treatment format and content preferences, which may inform future development. It also provides research data on the feasibility and acceptability of web-based applications for prenatal mental health care.

Trial Registration

ClinicalTrials.gov NCT01901796; https://clinicaltrials.gov/ct2/show/NCT01901796