Qualitative Synthesis of Young People's Experiences With Technology-Assisted Cognitive Behavioral Therapy: Systematic Review

Exploring experiences with an internet-delivered ACT intervention among individuals with a personal history of depression: A thematic analysis

This qualitative study explored the experiences of individuals testing a novel internet-delivered acceptance and commitment therapy program (iACT) for patients with mild and moderate depressive disorder. Twelve participants, consisting of one male and 11 females with a history of depression but not currently depressed were recruited. Individual semi-structured interviews were conducted after 14 days of access to the iACT without therapist guidance. By using reflexive thematic analysis three key themes reflecting important aspects of the participants' experiences were created. 'Theme 1: I would have been too ill to benefit from the program' points to generally positive sentiments about the program among participants but raised concerns about treatment adherence during a depressive episode. 'Theme 2: It has the potential to fill gaps in healthcare services' highlighted the program's perceived role as a supplement to current health services rather than as a standalone intervention. 'Theme 3: It is not perfect for anyone' underscored the participants different views on how their personal needs would be met by this program and the lack of tailoring to individual preferences. These findings provide valuable insights for refining future internet-delivered intervention development targeting patients with depression or other mental health challenges.

The evolution and mapping trends of mobile health (m-Health): a bibliometric analysis (1997-2023)

Background

Mobile health (m-Health) is widely acknowledged as a pivotal domain for improving global healthcare and driving its digital health transformation. Despite the vast amount of literature published in recent years, bibliometric studies on m-Health remain limited in scope and coverage. This study presents a comprehensive review of m-Health literature extracted from Scopus and PubMed databases, spanning the period from 1997 to 2023, including publications during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

The combined Scopus and PubMed databases were used in this study. The search formula for the literature retrieval used the most appropriate and relevant keywords to m-Health. The bibliometric data importation, extraction and analysis of authors, titles, publication date, publication place, publisher, volume number, issue number, citation count, document type, author keywords, affiliation were all carried out using the 'Biblioshiny', 'EndNote X9®', 'Microsoft Excel®' and 'Microsoft Access®' software tools. Duplicate records were manually identified and removed. Visualization maps illustrating the recurrent keywords, collaboration patterns, and prolific publishing countries were generated using 'VOSviewer®'.

Results

A total of 37,470 (20,703 from Scopus and 16,767 from PubMed) publications were selected for the literature analysis. The results provided the definitive literature evidence on the origin of the concept of m-Health in 2003. Significant increase in the publications followed the global surge of smart phones usage in 2007, and the emergence of m-Health applications (Apps) and their global markets and ecosystems. The number of the publications peaked between 2013 and 2022 with most citations in 2022. There was noticeable spike in m-Health literature during the COVID-19 pandemic. The results also showed that most of the highly cited publications, leading institutions, and most prolific authors were predominantly from the developed countries. The USA has the highest number of publications followed by the UK, Australia, Germany, Canada and China, with most of the prolific authors originating from these countries.

Conclusions

In conclusion, while there has been a remarkable increase in global m-Health publications since 2003, most of the impactful literature and publications in this area originated from selected countries in the developed world. The study indicates a significant disparity between the published literature from developed compared to the developing countries. Addressing this disparity, further bibliographical studies are required to address these and other literature gaps.

Facilitators and barriers to "Positive Outcomes" from cognitive-behavioral therapy, according to young people: A thematic synthesis

OBJECTIVE

This qualitative review sought to explore how young people (YP) conceptualize positive outcomes from cognitive-behavioral therapy (CBT) and what YP perceive to be the facilitators and barriers to positive outcomes.

METHODS

A systematic literature search was conducted in June 2021 using six online databases. Studies were included if qualitative data were collected from participants who were aged up to 25, had internalizing mental health difficulties, and had received in-person CBT from trained practitioners.

RESULTS

Nineteen studies were included. The Gough Weight of Evidence framework was used to assess methodological and topical quality and relevance. A thematic synthesis identified 34 conceptualizations of positive outcomes, 57 facilitators, and 49 barriers. Descriptive and analytical themes were identified. In line with the review's pragmatic perspective, the latter were worded as practice recommendations: acknowledge YP's perspectives on outcomes, teach tangible CBT techniques, balance autonomy and support, frame CBT as "upskilling," explore nuanced barriers to engagement, and consider the power of group dynamics.

CONCLUSIONS

This review established the range of YP's views about positive outcomes from CBT, as well as facilitators and barriers to achieving these. Findings should prompt CBT practitioners to reflect and consider how their practice might be shaped through reports from YP as experts by experience.

Is behavioural activation an effective treatment for depression in children and adolescents? An updated systematic review and meta-analysis

Behavioural Activation (BA)-a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities-is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA-delivered in-person, telephone, or online-for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge's adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.

Increasing the accessibility to internet-based cognitive behavioural therapy for depression: A single-blind randomized controlled trial of condensed versus full-text versions

Background

Research shows that internet-based cognitive behavioural therapy (iCBT) is an effective treatment for depression. However, little is known about how the length of the text material in iCBT affects outcomes.

Objective

The aim of this study was to test whether a condensed iCBT version for depression would be non-inferior to the existing full-text version in reducing depressive symptoms at post-treatment. We also wanted to test non-inferiority for secondary outcomes and explore reading speed and ADHD symptoms as potential moderators.

Method

A single-blind randomized controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; full-text (around 60,000 words) and condensed (around 30,000 words, with the option to listen to the text). Estimated between-group effect sizes and their confidence intervals for depression, anxiety and quality of life, were compared to a pre-determined non-inferiority margin (ES = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted.

Results

The condensed version of iCBT was non-inferior to the full-text version on post-treatment measures for depressive symptoms (95 % CI = -0.42-0.24), anxiety symptoms (95 % CI = -0.24-0.32), and quality of life (95 % CI = -0.09-0.49). Non-inferiority was inconclusive for depressive symptoms at the one-year follow-up (95 % CI = -0.60-0.47). There was no significant moderation effects of reading speed (p = 0.06) or ADHD symptoms (p = 0.11) on depressive symptoms.

Conclusion

These results indicate that a condensed version of iCBT for depression is as effective at treating depression as the full-text version. By shortening texts, iCBT may be made available to more people. Due to unequal dropout rates between the groups, these results are preliminary and need to be replicated.

Key Stakeholders' Experiences and Perceptions of Virtual Reality for Older Adults Living With Dementia: Systematic Review and Thematic Synthesis

BACKGROUND

Technology is increasingly being used and evolving in the dementia care landscape. One such technology that has gained traction over the last decade is virtual reality (VR). VR is being applied in many areas of dementia care, including cognitive assessment and training, reminiscence therapy, music therapy, and other recreational VR applications. Despite the plethora of applications, they are often not shaped by the experiences and perceptions of older adults living with dementia. Currently, there is no qualitative evidence synthesis (QES) to explore this area. This review aimed to provide qualitative evidence supporting existing systematic reviews in this area.

OBJECTIVE

The aim of this QES was to explore key stakeholders' experiences and perceptions of VR for older adults living with dementia. It aimed to explore the barriers and facilitators to VR use and provide recommendations for future design and implementation.

METHODS

QES was used, which involved a systematic search of 6 databases to identify studies that qualitatively explored key stakeholders' experiences and perceptions of VR for older adults living with dementia. Thematic synthesis was used to integrate the findings of 14 studies (from 15 reports). The Critical Appraisal Skills Programme tool was used to assess the methodological quality of the included studies. The confidence placed in the review findings was assessed using the GRADE-CERQUAL (Confidence in the Evidence from Reviews of Qualitative research).

RESULTS

A total of 15 reports from 14 studies were included in the review, consisting of a range of levels of VR immersion, stages of dementia, and care contexts. Three analytical themes were generated: stepping into virtuality, a virtual world, and returning to reality. The results indicate the importance of sensitively designing and introducing VR to this population, as older adults living with dementia often have no prior experience of using this technology. VR can be a positive experience for older adults living with dementia and can provide meaningful interactions, positive expressions, and long-term impacts on everyday functioning. However, it should be acknowledged that some negative associations must be accounted for before, during, and after use.

CONCLUSIONS

This review highlights the positive implications as well as negative associations of VR use. It emphasizes the need for VR design and implementation driven by the needs and views of older adults living with dementia as well as with other key stakeholders. Future research needs to explore the vital role that older adults living with dementia can play in the design process and how they can be empowered to meaningfully design and use this technology.

Applying technology to promote sexual and reproductive health and prevent gender based violence for adolescents in low and middle-income countries: digital health strategies synthesis from an umbrella review

AIM

Adolescents in low-and-middle-income countries (LMICs) are facing numerous developmental, sexual and reproductive health (SRH) challenges including exposure to multidimensional violence. Gender-based violence (GBV) specifically intimate partner violence (IPV) are both highly prevalent in LMICs and are strongly linked with poor SRH outcomes. However, GBV and IPV interventions have not yet been adequately integrated in SRH due to individual, social, cultural, service, and resource barriers. To promote long-term SRH, a more holistic approach that integrates GBV and IPV, and adolescent development needs is imperative. Digital health has the potential to address multiple service setup, provision, and addressing access barriers through designing and providing integrated SRH care. However, there are no guidelines for an integrated digital SRH and development promotion for adolescents in LMICs.

METHODS

An umbrella review was conducted to synthesize evidence in three inter-related areas of digital health intervention literature: (i) SRH, (ii) GBV specifically IPV as a subset, and (iii) adolescent development and health promotion. We first synthesize findings for each area of research, then further analyze the implications and opportunities to inform approaches to develop an integrated intervention that can holistically address multiple SRH needs of adolescents in LMICs. Articles published in English, between 2010 and 2020, and from PubMed were included.

RESULTS

Seventeen review articles met our review inclusion criterion. Our primary finding is that application of digital health strategies for adolescent SRH promotion is highly feasible and acceptable. Although effectiveness evidence is insufficient to make strong recommendations for interventions and best practices suggestions, some user-centered design guidelines have been proposed for web-based health information and health application design for adolescent use. Additionally, several digital health strategies have also been identified that can be used to further develop integrated GBV-IPV-SRH-informed services to improve adolescent health outcomes. We generated several recommendations and strategies to guide future digital based SRH promotion research from our review.

CONCLUSIONS

Rigorous research that focuses on intervention effectiveness testing using a combination of digital health strategies and standardized albeit contextualized outcome measures would be important. Methodological improvement such as adoption of longitudinal experimental design will be crucial in generating evidence-based intervention and practice guidelines for adolescents in LMICs.

The feasibility study of Internet-assisted play therapy to resolve psychological disorders in primary healthcare settings: A qualitative study

BACKGROUND

Play therapy is an intelligent tool in cognitive-behavioral therapies. In today's world, the Internet and technology play a key role in all aspects of people's life including mental health. The present study explores the feasibility of using Internet-assisted play therapy to solve children's psychological issues in primary healthcare systems.

MATERIALS AND METHODS

The present qualitative research was conducted by the content analysis approach on 20 experts working in the healthcare centers, who were selected purposefully. The sample was saturated with these 20 participants. Data were collected through semi-structured interviews and were coded manually. Then, they were analyzed in the Atlas.ti software package.

RESULTS

The results revealed 15 themes and 10 sub-themes. The themes included (1) safety, (2) efficiency, (3) client-orientedness, (4) organizational growth, (5) time, (6) effectiveness, (7) justice-orientedness, (8) access, (9) feedback, (10) analysis, (11) children's computer game room, (12) reward, (13) group game, and (14) capability to be integrated into other electronic programs.

CONCLUSION

It seems that Internet-based play therapy is plausible to be used as a service in primary healthcare to tackle the psychological problems of children in the target population if the challenges related to the exploratory themes are taken care of.

Improving management of needle distress during the journey to dialysis through psychological education and training-the INJECT study feasibility pilot protocol

BACKGROUND

Needle-related distress is a common yet poorly recognised and managed problem among haemodialysis (HD) patients. The aim of this pilot study is to test the feasibility and acceptability of the INJECT Intervention-an innovative psychology-based intervention to empower patients to self-manage needle distress with the support of dialysis nurses.

METHODS

This investigator-initiated, single-arm, non-randomised feasibility study will take place in a large dialysis service in Adelaide, Australia. Participants will include patients aged ≥ 18 years, commencing or already receiving maintenance HD, recruited through dialysis physicians and nursing staff as individuals believed to be at risk of needle distress. They will be screened for inclusion using the Dialysis Fear of Injection Questionnaire (DFIQ) and enrolled into the study if the score is ≥ 2. The multi-pronged intervention encompasses (i) psychologist review, (ii) patient self-management program and (iii) nursing education program. The primary aim is to evaluate feasibility and acceptability of the intervention from patient and dialysis nurse perspectives, including recruitment, retention, engagement with the intervention and completion. Secondary exploratory outcomes will assess suitability of various tools for measuring needle distress, evaluate acceptability of the nursing education program and measure cannulation-related trauma and vascular access outcomes.

CONCLUSION

The results will inform the protocol for larger trials addressing needle distress in HD patients.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000229875, approved 4 April 2021, https://www.anzctr.org.au/ .

Evaluating an engaging and coach-assisted online cognitive behavioral therapy for depression among adolescent and young adult cancer survivors: A pilot feasibility trial

OBJECTIVES

Technology-assisted Cognitive Behavioral Therapy (tCBT) has significant potentials to provide engaging and accessible depression treatment for adolescents and young adults (AYAs) coping with cancer. This study evaluated the feasibility and preliminary efficacy of an engaging and tailorable tCBT - Mind Your Total Health (MYTH) - for AYA cancer survivors' depression.

METHODS

Seventeen AYAs diagnosed with cancer were randomly assigned to either the intervention (MYTH) or control group. The intervention group (n = 10) received eight weekly 30-35 minutes coach-assisted tCBT (MYTH), while the control group (n = 7) received active control, BeatingtheBlues (BtB).

RESULTS

Eight out of ten participants in the MYTH group completed at least six out of eight sessions, suggesting strong feasibility (80% completion rate) among AYAs with cancer. Efficacy outcomes indicated that participants in the MYTH group reported significant pre- and post-treatment reduction in depression, t(9) = 5.25, p < 0.001, and anxiety, t(9)=5.07, p < 0.001. Notably, participants in the MYTH group reported significantly lower post-treatment depression than participants in the BtB group, t(15) = 2.40, p < 0.05. The between-group difference reflected a significant between-group treatment effect size, d = 1.12, p < 0.05.

DISCUSSION

This engaging, tailorable, and coach-assisted tCBT intervention is promising in alleviating depression and anxiety among AYA cancer survivors. Future research needs to include larger sample size and a more diverse patient population.

Pesky gNATs for children experiencing low mood and anxiety - A pragmatic randomised controlled trial of technology-assisted CBT in primary care

BACKGROUND

Compared to the evidence base for adult populations, less is known about the effectiveness of technology-assisted CBT interventions for children aged 12 and under in real-world settings.

AIMS

This study aimed to evaluate the effectiveness of a technology-assisted CBT intervention called Pesky gNATs in primary care psychology services.

METHODS

A 2 × 3 (group by time) waitlist randomised controlled trial design was applied (n = 122), using the total internalising score from the Child Behaviour Checklist (CBCL) as the primary outcome measure; and a range of secondary outcomes. Participants were recruited from primary care services across Ireland and were assessed at baseline (Time 1), post-intervention (Time 2), and a follow-up at 3 months (Time 3). Repeated measures ANOVAs were used to analyse the data; in addition to Cohen's d for effect sizes, and the reliable change index (RCI) for clinically meaningful change.

RESULTS

Overall, no significant between-group differences were found on primary or secondary measures. Both intervention and waitlist control groups experienced significantly positive change across all timepoints. However, participant retention rate at Time 2 was 66%; and fell to 44% at Time 3. Intervention group feedback from children and parent at Time 2 indicated high levels of acceptability and satisfaction with Pesky gNATs. The RCI showed a statistically significant result at Time 2: more participants from the intervention group (n = 9) moved from clinical to non-clinical levels on the primary outcome than did waitlist control participants (n = 0); but no differences were found at Time 3.

CONCLUSION

This RCT did not demonstrate that Pesky gNATs is effective in providing clinically significant levels of change for low mood and anxiety. However, participant feedback showed high levels of acceptability and positive experiences However, given the high attrition rate and implementation challenges, further research is required to ascertain the effectiveness of technology-assisted CBT interventions such as Pesky gNATs.

Experiences of an Online Treatment for Adolescents With Nonsuicidal Self-injury and Their Caregivers: Qualitative Study

Background

Nonsuicidal self-injury (NSSI) is common in adolescence and is associated with several adverse outcomes. Despite this, few established treatment options exist. Online treatment seems promising for several conditions; however, knowledge on NSSI is scarce. It is important to explore how online treatment for NSSI is experienced to improve such interventions and learn more about factors that are important in the treatment of adolescents with NSSI.

Objective

This study aims to explore the experiences of a novel online treatment for adolescents with NSSI and their caregivers.

Methods

A qualitative study using thematic analysis was conducted through semistructured interviews with 9 adolescents and 11 caregivers at treatment termination or at the 6-month follow-up of the online emotion regulation individual therapy for adolescents.

Results

A total of 3 overarching themes were identified. The theme support can come in different shapes showed how support could be attained through both interaction with the therapist as well as through the format itself (such as through the fictional characters in the material and the mobile app). Caregivers found it helpful to have their own online course, and adolescents accepted their involvement. The theme self-responsibility can be empowering as well as distressing showed that self-responsibility was highly appreciated (such as deciding when and how to engage in treatment) but also challenging; it caused occasional distress for some. The theme acquiring new skills and treatment effects showed the advantages and challenges of learning several different emotion regulation skills and that decreased emotion regulation difficulties were important treatment outcomes for adolescents. In addition, several different skills seemed to facilitate emotion regulation, and having access to such skills could hinder NSSI.

Conclusions

Online emotion regulation individual therapy for adolescents seems to offer an accepted way to deliver family interventions for this target group; facilitate skills training with several means of support, including support from both the mobile app and the therapist; contribute to decreasing emotion regulation difficulties and teaching skills that could hinder NSSI; and cause (in some individuals) distress because of the self-responsibility that is inherent to online formats, which needs to be addressed.

Perceptions of and Opinions on a Computerized Behavioral Activation Program for the Treatment of Depression in Young People: Thematic Analysis

BACKGROUND

Depression is one of the leading causes of illness and disability in young people, with approximately 20% having experienced a depressive episode by the age of 18 years. Behavioral activation (BA), a National Institute for Health and Care Excellence-recommended treatment for adults with depression, has shown preliminary support for its use with young people. BA may have the potential to be adapted and delivered in a computerized format to address the barriers often associated with young people accessing support. Despite the benefits of adopting computerized therapy delivery, the limited effectiveness of some programs has been attributed to a failure to tailor interventions to patients and practices. Therefore, while developing new treatments, it is important that target users be involved in the intervention design.

OBJECTIVE

This qualitative study aims to explore the views and preferences of young people and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression, to ensure that the therapy was suitable for the target user.

METHODS

Semistructured focus groups and individual interviews were conducted with young people (those with experience in accessing support and those without) and health care professionals regarding the development of a new computerized BA therapy for young people with low mood or depression. The data were analyzed using thematic analysis.

RESULTS

A total of 27 individuals, comprising both health care professionals and young people, participated in this study. Vital information pertaining to the important components of a new therapy, including its presentation, delivery, and content, was collected.

CONCLUSIONS

Variations in perspectives highlighted the need to adopt a systemic approach in therapy development by considering the opinions of young people with and without experience in accessing mental health support and health care professionals.

Experiences of online exposure-based treatment with parental support for teenagers with excessive worry

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Key learning aims

(1)

A qualitative evaluation of Pesky gNATs in primary care - The experiences of assistant psychologists providing computer-assisted CBT to children experiencing low mood and anxiety

INTRODUCTION

Technology-assisted cognitive behavioural therapy (CBT) is recognized as an evidence-based and cost-effective way to address psychological difficulties in children. Increasingly, these interventions are provided by staff with different levels of psychological training, such as assistant psychologists (APs). However, there is limited qualitative understanding regarding their experiences of providing technology-assisted CBT.

METHOD

Semi-structured interviews were conducted with APs (n = 14) in primary care settings in Ireland. This qualitative evaluation is part of an ongoing RCT for the CBT game Pesky gNATs (O'Reilly and Coyle, 2015). All data were inductively analysed using qualitative thematic analysis by Braun and Clarke (2006).

RESULTS

Five overarching themes were identified: 1) positive experiences, 2) integrating Pesky gNATs with traditional CBT, 3) managing parental 'buy-in', 4) implementation complexities, and 5) future perspectives. Two subthemes were reported for each overarching theme: benefits for children, AP professional growth, facilitating engagement, different child characteristics, unclear role for parents, child autonomy, managing waitlists, external factors, design considerations and advice to future APs.

CONCLUSIONS

Pesky gNATs is well-received by APs in primary care, and is mostly experienced as helpful by both APs and children. However, a number of factors may be impacting the ability of APs to effectively provide the intervention.