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Auerswald S, Koddebusch C, Hermann C. Elevated perceived stress in university students due to the COVID-19 pandemic: Potential contributing factors in a propensity-score-matched sample. Scand J Psychol 2024; 65:715-728. [PMID: 38497207 DOI: 10.1111/sjop.13013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE Onset of the Coronavirus Disease 2019 (COVID) pandemic has increased students' perceived burdens. The current study aimed to examine COVID-related changes and to identify potential factors that contribute to students' stress. METHOD Adopting a cross-sectional cohort-study design, we examined perceived stress and depressive and anxiety symptoms with a specific focus on the role of study-related variables such as perceived study-related demands, study-related resources, academic procrastination, and stress-enhancing beliefs. Two cohorts (Npre-COVID = 2,175; NCOVID = 959) were recruited at the same university and matched with regard to their propensity score (age, gender, semester). RESULTS Compared with the pre-COVID cohort, university students in the COVID cohort reported more perceived stress, more depressive and anxiety symptoms, more academic procrastination due to fear of failure, more stress-enhancing beliefs, more distress due to the housing situation, and more perceived study-related challenges (Cohen's d = 0.15-0.45). A stepwise regression analysis identified depressive symptoms, procrastination due to fear of failure, general self-efficacy, increased study demands, perceived difficulties with self-organized learning, distress due to housing, and stress-enhancing beliefs as predictors of perceived stress in the COVID cohort. DISCUSSION Findings suggest that the switch to online-only education increased the study-related burden for students, primarily due to exams being replaced by a greater amount of regular coursework and imposing demands on self-organized learning. Possibly, stress-enhancing beliefs and procrastination due to fear of failure might have been elevated due to less opportunity for social referencing and lack of felt social support by peer students. CONCLUSION Experienced increased burden in students during the COVID pandemic was mostly accounted for by a lack of perceived individual resources rather than by an increase in objective study-related demands.
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Affiliation(s)
- Sven Auerswald
- Department of Clinical Psychology and Psychotherapy, Justus-Liebig-University, Giessen, Germany
| | - Christine Koddebusch
- Department of Clinical Psychology and Psychotherapy, Justus-Liebig-University, Giessen, Germany
| | - Christiane Hermann
- Department of Clinical Psychology and Psychotherapy, Justus-Liebig-University, Giessen, Germany
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2
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Kukafka R, Dingemans AE, Evers C, Van Furth EF, Spinhoven P, Aardoom JJ, Lähde I, Clemens FC, Van den Akker-Van Marle ME. Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials. J Med Internet Res 2023; 25:e38204. [PMID: 36602854 PMCID: PMC9893732 DOI: 10.2196/38204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/27/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed. OBJECTIVE The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care. METHODS A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled. RESULTS The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results. CONCLUSIONS The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis. TRIAL REGISTRATION PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.
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Affiliation(s)
| | | | - Catharine Evers
- Department of Social, Health and Organizational Psychology, Utrecht University, Utrecht, Netherlands
| | - Eric F Van Furth
- GGZ Rivierduinen Eating Disorders Ursula, Leiden, Netherlands.,Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
| | - Philip Spinhoven
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands.,Institute of Psychology, Leiden University, Leiden, Netherlands
| | - Jiska J Aardoom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Irene Lähde
- GGZ Rivierduinen Eating Disorders Ursula, Leiden, Netherlands
| | - Fleur C Clemens
- GGZ Rivierduinen Eating Disorders Ursula, Leiden, Netherlands
| | - M Elske Van den Akker-Van Marle
- Section of Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
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3
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Kählke F, Buntrock C, Smit F, Ebert DD. Systematic review of economic evaluations for internet- and mobile-based interventions for mental health problems. NPJ Digit Med 2022; 5:175. [PMID: 36424463 PMCID: PMC9686241 DOI: 10.1038/s41746-022-00702-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
In view of the staggering disease and economic burden of mental disorders, internet and mobile-based interventions (IMIs) targeting mental disorders have often been touted to be cost-effective; however, available evidence is inconclusive and outdated. This review aimed to provide an overview of the cost-effectiveness of IMIs for mental disorders and symptoms. A systematic search was conducted for trial-based economic evaluations published before 10th May 2021. Electronic databases (including MEDLINE, PsycINFO, CENTRAL, PSYNDEX, and NHS Economic Evaluations Database) were searched for randomized controlled trials examining IMIs targeting mental disorders and symptoms and conducting a full health economic evaluation. Methodological quality and risk of bias were assessed. Cost-effectiveness was assumed at or below £30,000 per quality-adjusted life year gained. Of the 4044 studies, 36 economic evaluations were reviewed. Guided IMIs were likely to be cost-effective in depression and anxiety. The quality of most evaluations was good, albeit with some risks of bias. Heterogeneity across studies was high because of factors such as different costing methods, design, comparison groups, and outcomes used. IMIs for anxiety and depression have potential to be cost-effective. However, more research is needed into unguided (preventive) IMIs with active control conditions (e.g., treatment as usual) and longer time horizon across a wider range of disorders.Trial registration: PROSPERO Registration No. CRD42018093808.
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Affiliation(s)
- Fanny Kählke
- grid.6936.a0000000123222966Department of Sport and Health Sciences, Professorship of Psychology and Digital Mental Health Care, Technische Universität München, Munich, Germany
| | - Claudia Buntrock
- grid.5807.a0000 0001 1018 4307Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Germany
| | - Filip Smit
- grid.12380.380000 0004 1754 9227Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands ,grid.416017.50000 0001 0835 8259Centre of Health-Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
| | - David Daniel Ebert
- grid.6936.a0000000123222966Department of Sport and Health Sciences, Professorship of Psychology and Digital Mental Health Care, Technische Universität München, Munich, Germany
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4
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Muuraiskangas ST, Honka AM, Junno UM, Nieminen HO, Kaartinen JK. A Technology-Assisted Telephone Intervention for Work-Related Stress Management: Pilot Randomized Controlled Trial. J Med Internet Res 2022; 24:e26569. [PMID: 35830233 PMCID: PMC9330204 DOI: 10.2196/26569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 06/24/2021] [Accepted: 05/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background Stress management interventions combining technology with human involvement have the potential to improve the cost-effectiveness of solely human-delivered interventions, but few randomized controlled trials exist for assessing the cost-effectiveness of technology-assisted human interventions. Objective The aim of this study was to investigate whether a technology-assisted telephone intervention for stress management is feasible for increasing mental well-being or decreasing the time use of coaches (as an approximation of intervention cost) while maintaining participants’ adherence and satisfaction compared with traditional telephone coaching. Methods A 2-arm, pilot randomized controlled trial of 9 months for stress management (4-month intensive and 5-month maintenance phases) was conducted. Participants were recruited on the web through a regional occupational health care provider and randomized equally to a research (technology-assisted telephone intervention) and a control (traditional telephone intervention) group. The coaching methodology was based on habit formation, motivational interviewing, and the transtheoretical model. For the research group, technology supported both coaches and participants in identifying behavior change targets, setting the initial coaching plan, monitoring progress, and communication. The pilot outcome was intervention feasibility, measured primarily by self-assessed mental well-being (WorkOptimum index) and self-reported time use of coaches and secondarily by participants’ adherence and satisfaction. Results A total of 49 eligible participants were randomized to the research (n=24) and control (n=25) groups. Most participants were middle-aged (mean 46.26, SD 9.74 years) and female (47/49, 96%). Mental well-being improved significantly in both groups (WorkOptimum from “at risk” to “good” Â>0.85; P<.001), and no between-group differences were observed in the end (Â=0.56, 95% CI 0.37-0.74; P=.56). The total time use of coaches did not differ significantly between the groups (366.0 vs 343.0 minutes, Â=0.60, 95% CI 0.33-0.85; P=.48). Regarding adherence, the dropout rate was 13% (3/24) and 24% (6/25), and the mean adherence rate to coaching calls was 92% and 86% for the research and control groups, respectively; the frequency of performing coaching tasks was similar for both groups after both phases; and the diligence in performing the tasks during the intensive phase was better for the research group (5.0 vs 4.0, Â=0.58, 95% CI 0.51-0.65; P=.03), but no difference was observed during the maintenance phase. Satisfaction was higher in the research group during the intensive phase (5.0 vs 4.0, Â=0.66, 95% CI 0.58-0.73; P<.001) but not during the maintenance phase. Conclusions The technology-assisted telephone intervention is feasible with some modifications, as it had similar preliminary effectiveness as the traditional telephone intervention, and the participants had better satisfaction with and similar or better adherence to the intervention, but it did not reduce the time use of coaches. The technology should be improved to provide more digested information for action planning and templates for messaging. Trial Registration ClinicalTrials.gov NCT02445950; https://www.clinicaltrials.gov/ct2/show/study/NCT02445950
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Affiliation(s)
| | | | | | - Hannu Olavi Nieminen
- Movendos Ltd, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere university, Tampere, Finland
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5
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Gega L, Jankovic D, Saramago P, Marshall D, Dawson S, Brabyn S, Nikolaidis GF, Melton H, Churchill R, Bojke L. Digital interventions in mental health: evidence syntheses and economic modelling. Health Technol Assess 2022; 26:1-182. [PMID: 35048909 DOI: 10.3310/rcti6942] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Economic evaluations provide evidence on whether or not digital interventions offer value for money, based on their costs and outcomes relative to the costs and outcomes of alternatives. OBJECTIVES (1) Evaluate and summarise published economic studies about digital interventions across different technologies, therapies, comparators and mental health conditions; (2) synthesise clinical evidence about digital interventions for an exemplar mental health condition; (3) construct an economic model for the same exemplar mental health condition using the previously synthesised clinical evidence; and (4) consult with stakeholders about how they understand and assess the value of digital interventions. METHODS We completed four work packages: (1) a systematic review and quality assessment of economic studies about digital interventions; (2) a systematic review and network meta-analysis of randomised controlled trials on digital interventions for generalised anxiety disorder; (3) an economic model and value-of-information analysis on digital interventions for generalised anxiety disorder; and (4) a series of knowledge exchange face-to-face and digital seminars with stakeholders. RESULTS In work package 1, we reviewed 76 economic evaluations: 11 economic models and 65 within-trial analyses. Although the results of the studies are not directly comparable because they used different methods, the overall picture suggests that digital interventions are likely to be cost-effective, compared with no intervention and non-therapeutic controls, whereas the value of digital interventions compared with face-to-face therapy or printed manuals is unclear. In work package 2, we carried out two network meta-analyses of 20 randomised controlled trials of digital interventions for generalised anxiety disorder with a total of 2350 participants. The results were used to inform our economic model, but when considered on their own they were inconclusive because of the very wide confidence intervals. In work package 3, our decision-analytic model found that digital interventions for generalised anxiety disorder were associated with lower net monetary benefit than medication and face-to-face therapy, but greater net monetary benefit than non-therapeutic controls and no intervention. Value for money was driven by clinical outcomes rather than by intervention costs, and a value-of-information analysis suggested that uncertainty in the treatment effect had the greatest value (£12.9B). In work package 4, stakeholders identified several areas of benefits and costs of digital interventions that are important to them, including safety, sustainability and reducing waiting times. Four factors may influence their decisions to use digital interventions, other than costs and outcomes: increasing patient choice, reaching underserved populations, enabling continuous care and accepting the 'inevitability of going digital'. LIMITATIONS There was substantial uncertainty around effect estimates of digital interventions compared with alternatives. This uncertainty was driven by the small number of studies informing most comparisons, the small samples in some of these studies and the studies' high risk of bias. CONCLUSIONS Digital interventions may offer good value for money as an alternative to 'doing nothing' or 'doing something non-therapeutic' (e.g. monitoring or having a general discussion), but their added value compared with medication, face-to-face therapy and printed manuals is uncertain. Clinical outcomes rather than intervention costs drive 'value for money'. FUTURE WORK There is a need to develop digital interventions that are more effective, rather than just cheaper, than their alternatives. STUDY REGISTRATION This study is registered as PROSPERO CRD42018105837. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lina Gega
- Department of Health and Social Care Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK.,Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Dina Jankovic
- Centre for Health Economics, University of York, York, UK
| | - Pedro Saramago
- Centre for Health Economics, University of York, York, UK
| | - David Marshall
- Centre for Reviews & Dissemination, University of York, York, UK
| | - Sarah Dawson
- Common Mental Disorders Group, Cochrane Collaboration, University of York, York, UK.,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Sally Brabyn
- Department of Health and Social Care Sciences, University of York, York, UK
| | | | - Hollie Melton
- Centre for Reviews & Dissemination, University of York, York, UK
| | - Rachel Churchill
- Centre for Reviews & Dissemination, University of York, York, UK.,Common Mental Disorders Group, Cochrane Collaboration, University of York, York, UK
| | - Laura Bojke
- Centre for Health Economics, University of York, York, UK
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6
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Boß L, Angerer P, Dragano N, Ebert D, Engels M, Heber E, Kuhlmann R, Ruhle S, Schwens C, Wulf IC, Lehr D. Comparative effectiveness of guided internet-based stress management training versus established in-person group training in employees - study protocol for a pragmatic, randomized, non-inferiority trial. BMC Public Health 2021; 21:2177. [PMID: 34837999 PMCID: PMC8626923 DOI: 10.1186/s12889-021-12229-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occupational stress is a major public health challenge that requires a variety of evidence-based preventative approaches to increase their reach within the working population. Behavioral stress management interventions are considered an established approach for occupational stress prevention. Both in-person group-based stress management training (gSMT) and individual Internet-based training (iSMT) have been shown to be effective at reducing stress in employees. However, there remains a lack of evidence on the comparative efficacy of the newer digital format compared to well-established, in-person, group-based training. This study aims (1) to directly compare an evidence-based iSMT with an established gSMT on stress in employees, (2) to analyze the two conditions from a cost perspective, and (3) to explore moderators of the comparative efficacy. METHODS In a randomized, controlled, non-inferiority trial employees from the general working population will be allocated to iSMT or gSMT. The primary outcome will be perceived stress, assessed using the Perceived Stress Scale, three months after randomization. The non-inferiority margin for the primary outcome measure will be set at 2 points (Cohen's d = 0.29). This trial will also compare the two interventions from a health economics perspective, and conduct explorative analyses to identify potential effect moderators. DISCUSSION To reach a larger proportion of the working population, well-established gSMT should be complemented with interventions that fit today's society's increasingly digital lifestyle. The current trial will provide evidence supporting the responsible implementation of Internet-based stress management training if the digital format proves to at least be non-inferior to established group-based training. Additional explorative moderator analyses may guide future practices to aid in matching select programs with select users. TRIAL REGISTRATION German Register of Clinical Studies (DRKS): DRKS00024892, date of registration: 2021-04-09. Protocol version: 02, 16-10-2021.
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Affiliation(s)
- Leif Boß
- Department of Health Psychology and Applied Biological Psychology, Institute of Psychology, Leuphana University Lüneburg, Lüneburg, Germany.
| | - Peter Angerer
- Institute of Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty and University Hospital, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Nico Dragano
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty and University Hospital, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - David Ebert
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Miriam Engels
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty and University Hospital, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Elena Heber
- GET.ON Institut für Online Gesundheitstrainings GmbH, Hamburg, Germany
| | - Rebekka Kuhlmann
- Chair of Business Administration, in particular Work, Human Resource Management and Organization Studies, Faculty of Business Administration and Economics, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sascha Ruhle
- Chair of Business Administration, in particular Work, Human Resource Management and Organization Studies, Faculty of Business Administration and Economics, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Schwens
- Endowed Chair for Interdisciplinary Management Science, School of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Ines Catharina Wulf
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty and University Hospital, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Dirk Lehr
- Department of Health Psychology and Applied Biological Psychology, Institute of Psychology, Leuphana University Lüneburg, Lüneburg, Germany
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Nixon P, Boß L, Heber E, Ebert DD, Lehr D. A three-armed randomised controlled trial investigating the comparative impact of guidance on the efficacy of a web-based stress management intervention and health impairing and promoting mechanisms of prevention. BMC Public Health 2021; 21:1511. [PMID: 34353294 PMCID: PMC8339390 DOI: 10.1186/s12889-021-11504-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/16/2021] [Indexed: 02/08/2023] Open
Abstract
Background Web-based stress management interventions (SMI) fit increasingly digital lifestyles, reduce barriers of uptake and are easily scalable. SMIs might lower levels of stress in employees and thereby contribute to the prevention of depressive symptomatology. Different guidance formats can impact the efficacy of SMIs, with higher intensity assumed to result in larger effects. However, head-to-head comparisons of guidance formats are rare. This is the first trial to examine the impact of adherence-focused guidance compared to self-help on the efficacy of an occupational SMI compared to a wait list control condition. Additionally, it will be investigated if the SMI enfolds its impact on preventing depressive symptomatology by different pathways through reducing health impairing and increasing promoting factors. Methods A three-armed randomised controlled trial (RCT) on an occupational SMI was conducted. 404 employees with elevated levels of perceived stress (PSS-10 ≥ 22) were randomly assigned to: adherence-focused guidance (AFG), self-help (SH) or a wait list control group (WLC). The primary outcome was perceived stress (PSS-10). Secondary outcomes included health- and work-related measures. A parallel mediation analysis with stress and resilience as mediators for the effect on depression (CES-D) was carried out. Data collection took place at baseline (T1), after 7 weeks (T2) and 6 months (T3). Results The SMI was effective for all groups on the primary and secondary outcomes. For stress, analyses of covariance (ANCOVA) revealed significant group effects at T2 (F2,400 = 36.08, P < .001) and T3 (F2,400 = 37.04, P < .001) with large effect sizes for AFG (T2: d = 0.83; T3: d = 0.85) and SH (T2: d = 0.88; T3: d = 0.91) compared to WLC. No significant group differences were found for the efficacy between AFG and SH on the outcomes. Adherence in terms of completed modules was significantly higher for AFG compared to SH. The SMI’s impact on depression was mediated by perceived stress: a1b1 = − 0.77, 95% CI [− 1.26, − 0.34] and resilience: a2b2 = − 0.62, 95% CI [− 1.05, − 0.26]. Conclusions The SMI was effective for reducing stress and improving other health- and work-related outcomes, irrespective of the guidance format. Results did not demonstrate superiority of adherence-focused guidance for the efficacy but for adherence in terms of completed modules. Among other reasons, better communication strategies about offered guidance and awareness-raising measures are discussed. Results from mediation analysis suggest that preventive SMIs should be designed to reach two goals: reducing the risk factor of stress and simultaneously increasing health promoting factors such as resilience. Trial registration German Clinical Trial Registration (DRKS) DRKS00005687, 6/6/2014.
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Affiliation(s)
- Patricia Nixon
- Department of Health Psychology and Applied Biological Psychology, Institute of Psychology, Leuphana University of Lueneburg, Lueneburg, Germany
| | - Leif Boß
- Department of Health Psychology and Applied Biological Psychology, Institute of Psychology, Leuphana University of Lueneburg, Lueneburg, Germany
| | - Elena Heber
- Department for Sport & Health Sciences, Technical University of Munich, Psychology & Digital Mental Health Care, Munich, Germany
| | | | - Dirk Lehr
- Department of Health Psychology and Applied Biological Psychology, Institute of Psychology, Leuphana University of Lueneburg, Lueneburg, Germany.
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Buntrock C, Lehr D, Smit F, Horvath H, Berking M, Spiegelhalder K, Riper H, Ebert DD. Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Health-Economic Evaluation From the Societal and Public Health Care Perspective Alongside a Randomized Controlled Trial. J Med Internet Res 2021; 23:e25609. [PMID: 34028361 PMCID: PMC8185611 DOI: 10.2196/25609] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/12/2020] [Accepted: 04/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background The evidence base for internet-based cognitive behavioral therapy for insomnia (iCBT-I) is firm; however, little is known about iCBT-I’s health-economic effects. Objective This study aimed to evaluate the cost-effectiveness and cost–utility of iCBT-I in reducing insomnia among schoolteachers. Methods Schoolteachers (N=128) with clinically significant insomnia symptoms and work-related rumination were randomized to guided iCBT-I or a wait list control group, both with unrestricted access to treatment as usual. Health care use, patient and family expenditures, and productivity losses were self-assessed and used for costing from a societal and a public health care perspective. Costs were related to symptom-free status (score <8 on the insomnia severity index) and quality-adjusted life years (QALYs) gained. Sampling error was handled using nonparametric bootstrapping. Results Statistically significant differences favoring the intervention group were found for both health outcomes (symptom-free status yes or no: β=.30; 95% CI 0.16-0.43; QALYs: β=.019, 95% CI 0.01-0.03). From a societal perspective, iCBT-I had a 94% probability of dominating the wait list control for both health outcomes. From a public health care perspective, iCBT-I was more effective but also more expensive than the wait list control, resulting in an incremental cost-effectiveness ratio of €650 per symptom-free individual. In terms of QALYs, the incremental cost-effectiveness ratio was €11,285. At a willingness-to-pay threshold of €20,000 per QALY gained, the intervention’s probability of being cost-effective was 89%. Conclusions Our trial indicates that iCBT could be considered as a good value-for-money intervention for insomnia. Trial Registration German Clinical Trial Registry: DRKS00004700; https://tinyurl.com/2nnk57jm International Registered Report Identifier (IRRID) RR2-10.1186/1745-6215-14-169
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Affiliation(s)
- Claudia Buntrock
- Chair of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Dirk Lehr
- Institute of Psychology, Leuphana University Lueneburg, Lueneburg, Germany
| | - Filip Smit
- Center for Economic Evaluation and Machine Learning, Trimbos Insitute, Utrecht, Netherlands.,Department of Biostatistics and Epidemiology, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands.,Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Matthias Berking
- Chair of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Center University of Freiburg, Freiburg, Germany
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Telepsychiatric Centre, University of Southern Denmark, Odense, Denmark
| | - David Daniel Ebert
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
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9
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Lindsäter E, Axelsson E, Salomonsson S, Santoft F, Ljótsson B, Åkerstedt T, Lekander M, Hedman-Lagerlöf E. Cost-Effectiveness of Therapist-Guided Internet-Based Cognitive Behavioral Therapy for Stress-Related Disorders: Secondary Analysis of a Randomized Controlled Trial. J Med Internet Res 2019; 21:e14675. [PMID: 31586370 PMCID: PMC6788336 DOI: 10.2196/14675] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/14/2019] [Accepted: 07/27/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Stress-related disorders are associated with significant suffering, functional impairment, and high societal costs. Internet-based cognitive behavioral therapy (ICBT) is a promising treatment for stress-related disorders but has so far not been subjected to health economic evaluation. OBJECTIVE The objective of this study was to evaluate the cost-effectiveness and cost-utility of ICBT for patients with stress-related disorders in the form of adjustment disorder (AD) or exhaustion disorder (ED). We hypothesized that ICBT, compared with a waitlist control (WLC) group, would generate improvements at low net costs, thereby making it cost-effective. METHODS Health economic data were obtained in tandem with a randomized controlled trial of a 12-week ICBT in which patients (N=100) were randomized to an ICBT (n=50) or a WLC (n=50) group. Health outcomes and costs were surveyed pre- and posttreatment. We calculated incremental cost-effectiveness ratios (ICERs) based on remission rates and incremental cost-utility ratios (ICURs) based on health-related quality of life. Bootstrap sampling was used to assess the uncertainty of our results. RESULTS The ICER indicated that the most likely scenario was that ICBT led to higher remission rates compared with the WLC and was associated with slightly larger reductions in costs from pre- to posttreatment. ICBT had a 60% probability of being cost-effective at a willingness to pay (WTP) of US $0 and a 96% probability of being cost-effective at a WTP of US $1000. The ICUR indicated that ICBT also led to improvements in quality of life at no net societal cost. Sensitivity analyses supported the robustness of our results. CONCLUSIONS The results suggest that ICBT is a cost-effective treatment for patients suffering from AD or ED. Compared with no treatment, ICBT for these patients yields large effects at no or minimal societal net costs. TRIAL REGISTRATION ClinicalTrials.gov NCT02540317; https://clinicaltrials.gov/ct2/show/NCT02540317.
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Affiliation(s)
- Elin Lindsäter
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erland Axelsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sigrid Salomonsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Santoft
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Torbjörn Åkerstedt
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Mats Lekander
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Stress Research Institute, Stockholm University, Stockholm, Sweden.,Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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