Predictors, Outcomes, and Statistical Solutions of Missing Cases in Web-Based Psychotherapy: Methodological Replication and Elaboration Study

Moderators of outcome in self-guided internet-delivered cognitive-behavior therapy for obsessive-compulsive disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an effective treatment for obsessive-compulsive disorder (OCD). Currently there is limited research examining the predictors and moderators of outcome in ICBT for OCD. This study examined moderators of treatment outcome in a sample of 216 individuals who commenced a self-guided ICBT intervention for OCD (Mage = 34.00; SD = 12.57; 72.7% female). The results indicated that those with higher baseline OCD severity, depression severity, and neuroticism had less improvement at post-treatment and follow up (resulting in 40%, 24% and 12% higher symptom severity for every standard deviation increase on the measure at post-treatment and 33%, 17% and 20% higher symptoms at follow up respectively). However, participants with higher baseline treatment expectancy and readiness to reduce rituals and compulsions had better outcomes at post-treatment and three-month follow up (resulting in a 5% and 7% lower symptom severity for every standard deviation increase on the measure at post-treatment and 12% and 12% lower symptoms at follow up respectively). The results have important implications for who may respond best to self-guided ICBT.

The association between physical intervention use and treatment outcomes in patients participating in an online and psychologically informed pain management program

BACKGROUND

The availability of multidisciplinary care for the management of chronic pain is uncommon outside specialist clinics. The present study aims to determine the physical intervention use of patients participating in an online psychological pain management program and whether exposure to physical interventions in these patients alters treatment outcomes compared with patients who do not access physical interventions.

METHODS

Data were obtained from 2 previously published randomized controlled trials of an online psychological pain management program. Physical intervention exposure (categories: none, 1-3 sessions, 4+ sessions) was assessed at baseline, after treatment, and at 3-month follow-up. Primary outcomes included depression, anxiety, pain intensity, and pain-related disability. Generalized estimating equation models were used to compare treatment outcomes among those with different physical intervention frequencies and periods of exposure. We assessed whether changes in primary outcomes differed (moderated) by the period and category of physical intervention exposure.

RESULTS

Of the patients (n = 1074) who completed the baseline questionnaire across both randomized controlled trials, 470 (44%) reported physical intervention use at baseline, 383 (38%) reported physical intervention use after treatment, and 363 (42%) reported physical intervention use at 3-month follow-up. On average, there were moderate-large reductions from baseline to after treatment with respect to all outcomes (Cohen's d = 0.36-0.82). For all outcomes, the interaction of time by physical intervention exposure was statistically nonsignificant.

CONCLUSION

A substantial proportion of patients who participated in a psychologically informed pain management program were establishing, continuing, or stopping additional physical interventions. The frequency of and period of exposure to physical interventions did not appear to moderate treatment outcomes.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12613000252718 and ACTRN12615001003561). The website for registration information is https://www.anzctr.org.au.

Changes in the Frequency of Actions Associated With Mental Health During Online Treatment: Analysis of Demographic and Clinical Factors

BACKGROUND

Specific daily actions (eg, goal setting, meaningful activities) are associated with mental health. Performing specific daily actions at a higher frequency is associated with significantly lower baseline symptoms of depression and anxiety, as well as better psychological treatment outcomes for depression and anxiety.

OBJECTIVE

This study explored how the frequency of specific daily actions associated with mental health may differ prior to, during, and following treatment according to demographic and clinical characteristics.

METHODS

Using a sample of 448 patients from an Australian national digital psychology service, we examined baseline differences in daily action frequency and changes in daily action frequency during a digital psychological treatment according to demographic and clinical subgroups. A total of 5 specific types of daily actions were measured using the Things You Do Questionnaire: healthy thinking, meaningful activities, goals and plans, healthy habits, and social connections.

RESULTS

The frequency of daily actions differed according to employment status (largest P=.005) and educational level (largest P=.004). Daily action frequency was lower in those participants with more severe or chronic depression or anxiety symptoms (largest P=.004). Participants reported larger increases in how often they did these daily actions from baseline to midtreatment compared to mid- to posttreatment. Depression duration (P=.01) and severity (P<.001) were associated with differences in how daily action frequency changed during treatment.

CONCLUSIONS

The findings of this study support continued research exploring the relationship between daily actions and mental health, how this relationship might differ between individuals, and the clinical potential of supporting individuals to increase the frequency of daily actions to improve mental health.

Measurement of Daily Actions Associated With Mental Health Using the Things You Do Questionnaire-15-Item: Questionnaire Development and Validation Study

BACKGROUND

A large number of modifiable and measurable daily actions are thought to impact mental health. The "Things You Do" refers to 5 types of daily actions that have been associated with mental health: healthy thinking, meaningful activities, goals and plans, healthy habits, and social connections. Previous studies have reported the psychometric properties of the Things You Do Questionnaire (TYDQ)-21-item (TYDQ21). The 21-item version, however, has an uneven distribution of items across the 5 aforementioned factors and may be lengthy to administer on a regular basis.

OBJECTIVE

This study aimed to develop and evaluate a brief version of the TYDQ. To accomplish this, we identified the top 10 and 15 items on the TYDQ21 and then evaluated the performance of the 10-item and 15-item versions of the TYDQ in community and treatment-seeking samples.

METHODS

Using confirmatory factor analysis, the top 2 or 3 items were used to develop the 10-item and 15-item versions, respectively. Model fit, reliability, and validity were examined for both versions in 2 samples: a survey of community adults (n=6070) and adults who completed an assessment at a digital psychology service (n=14,878). Treatment responsivity was examined in a subgroup of participants (n=448).

RESULTS

Parallel analysis supported the 5-factor structure of the TYDQ. The brief (10-item and 15-item) versions were associated with better model fit than the 21-item version, as revealed by its comparative fit index, root-mean-square error of approximation, and Tucker-Lewis index. Configural, metric, and scalar invariance were supported. The 15-item version explained more variance in the 21-item scores than the 10-item version. Internal consistency was appropriate (eg, the 15-item version had a Cronbach α of >0.90 in both samples) and there were no marked differences between how the brief versions correlated with validated measures of depression or anxiety symptoms. The measure was responsive to treatment.

CONCLUSIONS

The 15-item version is appropriate for use as a brief measure of daily actions associated with mental health while balancing brevity and clinical utility. Further research is encouraged to replicate our psychometric evaluation in other settings (eg, face-to-face services).

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000407796; https://tinyurl.com/2s67a6ps.

Things You Do: A randomized controlled trial of an unguided ultra-brief intervention to reduce symptoms of depression and anxiety

The 'Things You Do' encompass five types of actions that are strongly associated with good mental health: Healthy Thinking, Meaningful Activities, Goals and Plans, Healthy Habits, and Social Connections. Ultra-brief interventions which increase how often people perform these actions may decrease depression and anxiety. A two-arm randomized controlled trial (N = 349) compared an unguided ultra-brief intervention based on the 'Things You Do' against a waitlist control. The intervention included one online module, two practice guides, and four weeks of daily text messages. The primary timepoint was 5-weeks post-baseline. The intervention resulted in moderate reductions in depression (d = 0.51) and anxiety (d = 0.55) alongside moderate increases in the frequency of Things You Do actions (d = 0.54), compared to controls. No significant change in number of days out of role or life satisfaction were observed. Treatment completion was high (92 %), most participants reported being satisfied with the treatment (66 %), and improvements were maintained at 3-month follow-up. This study demonstrated that an automated ultra-brief 'Things You Do' intervention resulted in clinically significant reductions in depression and anxiety. Ultra-brief interventions may provide a scalable solution to support individuals who are unlikely to engage in longer forms of psychological treatment.

Internet-Delivered Psychological Pain-Management for Young Adults With Chronic Pain: An Investigation of Clinical Trial Data

Young adults report chronic pain at rates of around 12% but lack access to clinical services. There is interest in learning how this emerging adult population engages with and responds to treatment. Using data from young adults aged 18 to 30 years (Mage = 25.8, SD = 3.2), taken from 4 previous randomised controlled trials, the current study investigated the feasibility, acceptability, and efficacy of an internet-delivered psychological pain-management intervention for young adults with chronic pain. We compared young adults in a treatment group (n = 104) with 1) a young-adult wait-list control group (n = 48), and 2) a treatment group reflecting the average-aged participant from the previous trials (39-63 years, n = 561). Feasibility was determined through treatment engagement, adherence and completion, and acceptability through a treatment satisfaction measure. Clinical outcomes were disability, pain intensity, anxiety, and depression; assessed at pre-treatment, post-treatment, and 3-month follow-up. Generalised estimation equation analyses were undertaken, using multiple imputations to account for missing data. Young adults had high engagement and acceptability ratings, though 34% did not complete the intervention. The treatment group significant improved across all outcomes, compared with control, with improvements maintained at follow-up. Post-treatment improvements were equivalent for young-adult and average-aged adult treatment groups, with no significant differences in feasibility or acceptability outcomes. Findings indicate young adults can engage with and show improvements following a psychological pain-management intervention designed for all adults with chronic pain. Future research is encouraged to examine outcomes related to role functioning of young adults, and moderators of treatment acceptability and efficacy for this population. PERSPECTIVE: Secondary analysis of data from 4 RCTs found an Internet-delivered psychological pain-management intervention acceptable and clinically efficacious for improving disability, anxiety, depression and pain intensity in young adults (18-30) with chronic pain.

Sudden gains in depression and anxiety during an online pain management programme for chronic pain

BACKGROUND

Chronic pain is associated with depression and anxiety symptoms. Pain management programms, delivered face-to-face or via the internet, can effectively help adults manage the impacts of chronic pain. Sudden gains are defined as substantial, rapid, and lasting symptom reductions that occur between consecutive treatment sessions and have been associated with better treatment outcomes in non-pain samples. This study examined whether adults with chronic pain report sudden gains in depression or anxiety symptoms during an 8-week online pain management programme, and whether sudden gains were associated with better treatment outcomes for depression or anxiety. Dominant theories of sudden gains argue that therapists are required for sudden gains to be maintained and improve treatment outcomes.

METHODS

Using data from a published randomized controlled trial (n = 338), sudden gains and treatment outcomes were compared across three levels of therapist guidance provided alongside the programme: weekly, optional, and self-guided.

RESULTS

Similar rates of sudden gains were observed in depression (22%) and anxiety (24%) across the treatment period, and most sudden gains occurred between Weeks 1 and 2 of treatment. Therapist guidance was not associated with sudden gains; higher baseline symptom severity emerged as the only consistent predictor of sudden gain status. No significant differences in treatment outcomes for depression or anxiety symptoms between sudden gainers and non-gainers were observed across therapist guidance conditions.

CONCLUSIONS

These results do not support an association between sudden gains in depression or anxiety symptoms and better post-treatment outcomes, at least for adults with chronic pain.

SIGNIFICANCE STATEMENT

Sudden gains in depression and anxiety symptoms were not associated with improved treatment outcomes for adults with chronic pain who participated in an online pain management programme, regardless of the level of therapist guidance provided. These findings suggest possible differences in symptom change in chronic pain samples compared to general population samples.

Comparative effectiveness of digital mental healthcare models for adults with epilepsy: A study protocol of a randomized controlled trial

OBJECTIVE

Mental health complaints are prevalent among people with epilepsy, yet there are major barriers that prevent access to psychological care, including high out-of-pocket costs and a lack of accessible specialized services. The purpose of the current study is to examine the comparative efficacy, acceptability, cost-effectiveness, and long-term outcomes of a digital psychological intervention when delivered under two models of care (i.e., guided vs. unguided) in supporting the mental health and functioning of adults with epilepsy.

METHOD

Approximately 375 participants across Australia will be enrolled. Eligible participants will have a confirmed diagnosis of epilepsy, experience difficulties with their emotional health, be at least 18 years of age, and live in Australia. Participants will be randomized (2:2:1) to receive the Wellbeing Neuro Course, a 10-week internet-delivered program, with (i.e., guided) or without guidance by a mental health clinician (i.e., unguided), or be allocated to a treatment-as-usual waiting-list control group. Participants will complete online questionnaires at pre-, post-treatment, and 3- and 12-month follow-up and consent to have their data linked to their medical records to capture healthcare system resource use and costs.

ANALYSIS

Primary outcome measures will be symptoms of depression and anxiety. A cost-utility analysis will be undertaken using the Australian healthcare system perspective and according to current economic evaluation guidelines. Resource use and costs to the healthcare system during the study period will be captured via data linkage to relevant administrative datasets in Australia.

SIGNIFICANCE

The results of this trial will provide important data concerning the relative outcomes of these different models of care and will inform the integration of digital psychological interventions translation into healthcare services.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee of Macquarie University approved the proposed study (Reference No: 520231325151475). The results will be disseminated through peer-reviewed publication(s).

ANZCTR TRIAL REGISTRATION NUMBER

ACTRN12623001327673.

PLAIN LANGUAGE SUMMARY

This study seeks to find out if a 10-week online psychological treatment can improve the mental health and well-being of Australian adults with epilepsy. Around 375 participants will be randomly assigned to different groups: one will receive treatment with guidance from mental health clinician (guided group), one without guidance (unguided group), and one starting later (waiting control group). All participants will fill out the same outcome measures online. The main goal of this research is to compare these groups and assess how well the treatment works in improving mental health outcomes.

Treating child anxiety using family-based internet delivered cognitive behavior therapy with brief therapist guidance: A randomized controlled trial

Online treatment delivery has the potential to increase access to evidence-based mental health care for children with anxiety disorders. Using a randomized controlled trial design, we evaluated the efficacy of Cool Kids Online, a family-based and therapist supported internet-delivered cognitive behavioral treatment (CBT) designed to target anxiety disorders in children. Ninety-five children aged 7-12 years with a DSM-5 anxiety disorder were randomly allocated to Cool Kids Online or a waitlist control. Children were assessed at baseline, week 11, and 6-months following treatment. Children in waitlist received treatment after week 11 and also completed assessments immediately and six months after treatment, allowing treatment maintenance to be evaluated for all children. Compared to waitlist, Cool Kids Online led to significantly greater remission of anxiety disorders (primary and all anxiety diagnoses) and greater reduction of caregiver-reported anxiety symptoms and interference at week 11. Child-reported anxiety symptoms and interference and child- and caregiver-reported depressive or externalizing symptoms did not differ significantly between conditions. Medium to large within-treatment effects were observed for all children from pre to post treatment with post treatment effects maintained until follow-up. Overall, the findings provide support for the efficacy of the program in treating anxiety. Cool Kids Online compared to waitlist for the remission of anxiety disorders in clinically anxious children; anzctr.org.au; ACTRN12615000947505.

Predictors of Dropout Among Psychosomatic Rehabilitation Patients During the COVID-19 Pandemic: Secondary Analysis of a Longitudinal Study of Digital Training

BACKGROUND

High dropout rates are a common problem reported in web-based studies. Understanding which risk factors interrelate with dropping out from the studies provides the option to prevent dropout by tailoring effective strategies.

OBJECTIVE

This study aims to contribute an understanding of the predictors of web-based study dropout among psychosomatic rehabilitation patients. We investigated whether sociodemographics, voluntary interventions, physical and mental health, digital use for health and rehabilitation, and COVID-19 pandemic-related variables determine study dropout.

METHODS

Patients (N=2155) recruited from 4 psychosomatic rehabilitation clinics in Germany filled in a web-based questionnaire at T1, which was before their rehabilitation stay. Approximately half of the patients (1082/2155, 50.21%) dropped out at T2, which was after the rehabilitation stay, before and during which 3 voluntary digital trainings were provided to them. According to the number of trainings that the patients participated in, they were categorized into a comparison group or 1 of 3 intervention groups. Chi-square tests were performed to examine the differences between dropout patients and retained patients in terms of sociodemographic variables and to compare the dropout rate differences between the comparison and intervention groups. Logistic regression analyses were used to assess what factors were related to study dropout.

RESULTS

The comparison group had the highest dropout rate of 68.4% (173/253) compared with the intervention groups' dropout rates of 47.98% (749/1561), 50% (96/192), and 42.9% (64/149). Patients with a diagnosis of combined anxiety and depressive disorder had the highest dropout rate of 64% (47/74). Younger patients (those aged <50 y) and patients who were less educated were more likely to drop out of the study. Patients who used health-related apps and the internet less were more likely to drop out of the study. Patients who remained in their jobs and patients who were infected by COVID-19 were more likely to drop out of the study.

CONCLUSIONS

This study investigated the predictors of dropout in web-based studies. Different factors such as patient sociodemographics, physical and mental health, digital use, COVID-19 pandemic correlates, and study design can correlate with the dropout rate. For web-based studies with a focus on mental health, it is suggested to consider these possible dropout predictors and take appropriate steps to help patients with a high risk of dropping out overcome difficulties in completing the study.

Mindfulness-enhanced internet-based cognitive behavioural therapy for anxiety and depression: Outcomes in routine care

BACKGROUND

Clinical trials support the efficacy of mindfulness-enhanced, internet-based cognitive behavioural therapies (CBT) in reducing anxiety and depression symptom severity. However, it is unclear how effective these interventions are when delivered in routine clinical care settings. This study investigated the utilisation and treatment outcomes of an online mindfulness-enhanced CBT program in the general Australian community.

METHODS

Over a one-year study period, 2187 adults commenced the online mindfulness-enhanced CBT program. The program consisted of six sequential lessons to be completed within 90 days. Participants (mean age= 39 ± 14 years, 68 % female) completed measures of symptom severity for anxiety, depression, and psychological distress at pre-, mid- and post-treatment. Treatment effects were assessed via intention-to-treat linear mixed models with Hedges' g effect size calculations.

RESULTS

From pre- to post-treatment, the mindfulness-enhanced CBT program was associated with medium and large effect sized reductions in generalised anxiety symptom severity (g = 0.80, 95%CI: 0.74-0.86), depression symptom severity (g = 0.74, 95%CI: 0.68-0.80), and psychological distress (g = 0.97, 95%CI: 0.90-1.03). Program adherence was modest with approximately 30 % of participants completing all six lessons of the program.

LIMITATIONS

This study is limited by its lack of a comparator condition, longer-term follow-up, and assessment of the reasons for participant non-adherence. The relative acceptability and effectiveness of mindfulness versus CBT components was not examined.

CONCLUSION

This study supports the effectiveness of mindfulness-enhanced iCBT for symptoms of anxiety and depression when delivered in a routine care setting under the supervision of community health care practitioners.

The Timing and Magnitude of Improvements in Depression, Anxiety, Disability, and Pain Intensity During an Internet-delivered Program for Chronic Pain

Numerous studies have found that pain management programs are an effective treatment option for people with chronic pain. However, little is known about when people experience improvements during these programs and why they are effective. Using a secondary analysis, the current study examined the timing and magnitude of symptom change during an 8-week internet-delivered psychological pain management program for people with chronic pain. The change in 4 outcomes was examined: depression (n = 881), anxiety (n = 561), disability (n = 484), and pain intensity (n = 484). The largest improvements in depression, anxiety, and disability were reported during the first half of treatment (ie, 4 weeks), whereas the largest reductions in pain intensity were reported during the second half of treatment. Half the participants had experienced a clinically meaningful improvement in depression or anxiety, and a third of participants had reported such an improvement in disability by midtreatment (ie, 5 weeks after baseline). In a subgroup analysis (n = 397), this pattern of change in depression and anxiety symptoms did not differ based on the level of therapist guidance. This study highlights the importance of the first few weeks of psychological pain management programs and encourages future work to examine how the mechanisms underpinning rapid change may be harnessed to optimize care for people with chronic pain. PERSPECTIVE: This study found that depression, anxiety, and disability improved rapidly during the first half of an 8-week internet-delivered pain management program, and most of the prepost change had occurred by midtreatment. This work highlights the therapeutic potential of the first few treatment sessions and prompts future research into a rapid responding.

Predicting Youth and Young Adult Treatment Engagement in a Transdiagnostic Remote Intensive Outpatient Program: Latent Profile Analysis

BACKGROUND

The youth mental health crisis in the United States continues to worsen, and research has shown poor mental health treatment engagement. Despite the need for personalized engagement strategies, there is a lack of research involving youth. Due to complex youth developmental milestones, there is a need to better understand clinical presentation and factors associated with treatment engagement to effectively identify and tailor beneficial treatments.

OBJECTIVE

This quality improvement investigation sought to identify subgroups of clients attending a remote intensive outpatient program (IOP) based on clinical acuity data at intake, to determine the factors associated with engagement outcomes for clients who present in complex developmental periods and with cooccurring conditions. The identification of these subgroups was used to inform programmatic decisions within this remote IOP system.

METHODS

Data were collected as part of ongoing quality improvement initiatives at a remote IOP for youth and young adults. Participants included clients (N=2924) discharged between July 2021 and February 2023. A latent profile analysis was conducted using 5 indicators of clinical acuity at treatment entry, and the resulting profiles were assessed for associations with demographic factors and treatment engagement outcomes.

RESULTS

Among the 2924 participants, 4 profiles of clinical acuity were identified: a low-acuity profile (n=943, 32.25%), characterized by minimal anxiety, depression, and self-harm, and 3 high-acuity profiles defined by moderately severe depression and anxiety but differentiated by rates of self-harm (high acuity+low self-harm: n=1452, 49.66%; high acuity+moderate self-harm: n=203, 6.94%; high acuity+high self-harm: n=326, 11.15%). Age, gender, transgender identity, and sexual orientation were significantly associated with profile membership. Clients identified as sexually and gender-marginalized populations were more likely to be classified into high-acuity profiles than into the low-acuity profile (eg, for clients who identified as transgender, high acuity+low self-harm: odds ratio [OR] 2.07, 95% CI 1.35-3.18; P<.001; high acuity+moderate self-harm: OR 2.85, 95% CI 1.66-4.90; P<.001; high acuity+high self-harm: OR 3.67, 95% CI 2.45-5.51; P<.001). Race was unrelated to the profile membership. Profile membership was significantly associated with treatment engagement: youth and young adults in the low-acuity and high-acuity+low-self-harm profiles attended an average of 4 fewer treatment sessions compared with youth in the high-acuity+moderate-self-harm and high-acuity+high-self-harm profiles (ꭓ23=27.6, P<.001). Individuals in the high-acuity+low-self-harm profile completed treatment at a significantly lower rate relative to the other 2 high-acuity profiles (ꭓ23=13.4, P=.004). Finally, those in the high-acuity+high-self-harm profile were significantly less likely to disengage early relative to youth in all other profiles (ꭓ23=71.12, P<.001).

CONCLUSIONS

This investigation represents a novel application for identifying subgroups of adolescents and young adults based on clinical acuity data at intake to identify patterns in treatment engagement outcomes. Identifying subgroups that differentially engage in treatment is a critical first step toward targeting engagement strategies for complex populations.

An open trial of the feasibility of brief internet-delivered acceptance and aommitment therapy (iACT) for chronic anxiety and depression

Anxiety and depressive disorders are common, often chronic and result in significant disability and distress. The delivery of psychological interventions via the internet is now recognised to be a safe and effective way to treat these disorders. The predominant therapeutic model in clinical trials and in routine care has been cognitive-behavioural therapy (CBT), which helps patients identify and modify unhelpful thoughts and behaviours. However, other models of treatment for anxiety and depression, such as acceptance and commitment therapy (ACT), which uses the examination of both positive and negative experiences in the service of living a personally meaningful and values-based life, have been developed and tested, although most of these interventions are long and require more clinician support to ensure adherence and achieve positive outcomes. The aim of the present study was to examine the feasibility of a new brief, clinician supported transdiagnostic internet-delivered (iACT) program, designed to treat symptoms of both anxiety and depression and improve social function. A single-group open trial was conducted on 24 adults with long-term symptoms of anxiety and depression. The course is comprised of five online modules delivered over 8 weeks either self-guided or with support from a clinician. There was a high course completion rate (70 %) and a high level of satisfaction with the course (94 % satisfied or very satisfied). Significant clinical improvement in our primary outcome measures (within-group Cohen's d) of anxiety (d ≥ 0.62), depression (d ≥ 0.63), disability (d ≥ 0.43) and quality of life (d ≥ -0.57) were observed at posttreatment. Relatively little clinician time was required per participant (M = 30.6 min, SD = 5.7). The findings of the current study support the feasibility and potential of a transdiagnostic iACT treatment for adults experiencing long-term symptoms of anxiety and depression, including those patients who have not derived benefit from other treatments.

Effectiveness of internet delivered cognitive behaviour therapy provided as routine care for people in the depressed phase of bipolar disorder treated with Lithium

There is little research reporting the outcome of internet delivered cognitive behaviour therapy, (iCBT), which helps patients identify and modify unhelpful cognitions and behaviours, for the depressed phase of bipolar disorder as part of routine care. Demographic information, baseline scores and treatment outcomes were examined for patients of MindSpot Clinic, a national iCBT service who reported taking Lithium and their clinic records confirmed the diagnosis of bipolar disorder. Outcomes were completion rates, patient satisfaction and changes in measures of psychological distress, depression and anxiety measured by the Kessler-10 item (K-10), Patient Health Questionnaire 9 Item (PHQ-9), and Generalized Anxiety Disorder Scale 7 Item (GAD-7), compared to clinic benchmarks. Out of 21,745 people who completed a MindSpot assessment and enrolled in a MindSpot treatment course in a 7 year period, 83 reported taking Lithium and had a confirmed a diagnosis of bipolar disorder. Outcomes of reductions in symptoms were large on all measures (effect sizes > 1.0 on all measures, percentage change between 32.4% and 40%), and lesson completion and satisfaction with the course were also high. MindSpot treatments appear to be effective in treating anxiety and depression in people diagnosed with bipolar, and suggest that iCBT has the potential to overcome the under-use of evidence based psychological treatments of people with bipolar depression.

A meta-analytic review of randomized clinical trials of online treatments for anxiety: Inclusion/exclusion criteria, uptake, adherence, dropout, and clinical outcomes

Over the last decade there has been rapid growth in the number of clinical trials examining internet-delivered interventions for anxiety. While there have been numerous analyses of treatment efficacy, few studies have examined treatment engagement. The current meta-analysis examined participant eligibility, uptake, adherence, and drop-out in clinical trials of internet-delivered treatments for anxiety. This meta-analysis used random effects models to obtain estimates of participant inclusion, uptake, adherence, drop-out, and within-group treatment effect size. Moderator analyses examined the effects of anxiety disorder type, treatment type, and level of clinician guidance. After screening, 140 trials with 199 treatment arms (N = 11,021) were included. An average of 46% (95% CI 42, 50) of interested people were included in the clinical trials. In the active treatment arms, 98% (95% CI 97, 99) of participants began treatment, 81% (95% CI 78, 85) of the assigned treatments were completed, 21% (95% CI 18, 23) of individuals dropped out at post-treatment based on questionnaire non-completion, and an overall within-group effect size of g = 1.03 (95% CI 0.94, 1.13) was obtained. Several moderators of interest were significant (e.g., clinical guidance, anxiety disorder type), and there was substantial heterogeneity in estimates. In conclusion, a large number of inclusion and exclusion criteria have been used in trials of internet-delivered treatments for anxiety. Once recruited into a trial, however, most people appear to begin, adhere, and complete internet-delivered treatment for anxiety. Further research exploring various eligibility criteria and their impact on engagement and efficacy is warranted.

Can Internet-Delivered Pain Management Programs Reduce Psychological Distress in Chronic Pain? Exploring Relationships Between Anxiety and Depression, Pain Intensity, and Disability

Background

Adults with chronic pain who also report high pain intensity and disability are more likely to experience depression and anxiety symptoms. The present study examined changes in anxiety and depression symptoms after an Internet-delivered pain management program based on baseline pain intensity and disability severity categories.

Methods

We conducted a secondary analysis of data from four randomized controlled trials (N = 1,333).

Results

Greater pain intensity and disability were associated with increased odds of elevated anxiety or depression symptoms at baseline. Treatment led to greater reductions in anxiety and depression symptoms compared with a waitlist control, and these improvements occurred irrespective of baseline pain intensity or disability severity. Those individuals who reported ≥30% improvements in pain intensity or disability after treatment were more likely to also report ≥30% improvements in psychological symptoms. Importantly, most participants who achieved ≥30% improvements in depression and anxiety had not experienced such improvements in pain intensity or disability.

Conclusion

These findings suggest that emerging Internet-delivered pain management programs can lead to reductions in psychological distress even when pain intensity and disability are severe or do not improve with treatment. This indicates the value of such treatments in treating distress and improving mental health in people with chronic pain.

Examining Change in the Frequency of Adaptive Actions as a Mediator of Treatment Outcomes in Internet-Delivered Therapy for Depression and Anxiety

Adaptive actions, including healthy thinking and meaningful activities, have been associated with emotional wellbeing. The Things You Do Questionnaire-21 item (TYDQ-21) has recently been created to measure the frequency of such actions. A study using the TYDQ-21 found that adaptive actions increased across Internet-delivered therapy for symptoms of depression and anxiety, and higher TYDQ-21 scores were associated with lower psychological distress at post-treatment. The current study examined the relationships between adaptive actions and psychological distress among adults (n = 1114) receiving Internet-delivered therapy as part of routine care in Canada, and explored whether adaptive actions mediated reductions in depression and anxiety. As hypothesised, adaptive actions increased alongside reductions in depression and anxiety symptoms from baseline to post-treatment. Treatment effects were consistent when the intervention was provided with regular weekly therapist support or with optional weekly therapist support, and some (but not all) types of adaptive actions had a mediating effect on change in depressive symptoms. The present findings support further work examining adaptive actions as a mechanism of change in psychotherapy, as well as the utility and scalability of Internet-delivered treatments to target and increase adaptive actions with the aim of improving mental health.

Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Symptoms of Postpartum Anxiety and Depression: Feasibility Randomized Controlled Trial

Background

Postpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and are associated with significant personal and economic costs. Fewer than half of the mothers experiencing PPD or PPA symptoms receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behavioral therapy (ICBT).

Objective

This pilot study aimed to examine the impact of a therapist-assisted, transdiagnostic ICBT program on symptoms of PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population, which did not include therapist assistance.

Methods

Clients endorsing the symptoms of PPD or PPA (N=63) were randomized to an 8-week transdiagnostic ICBT course (Wellbeing Course for New Moms) or to treatment as usual (TAU). Clients completed measures of depression, anxiety, stress, postnatal bonding, and relationship satisfaction, as well as measures of treatment satisfaction and therapeutic alliance, before treatment, after treatment, and at the 1-month follow-up. Outcome measures were also completed at the 6-month follow-up for clients who completed the ICBT course.

Results

Both the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements after treatment and at the 1-month follow-up on more measures than the TAU group, with medium between-group Cohen d effects on primary outcome measures for anxiety (Cohen d=0.65, 95% CI 0.13-1.17), PPD (Cohen d=0.52, 95% CI 0.01-1.04), and depression (Cohen d=0.56, 95% CI 0.05-1.08), and on secondary outcome measures of overall distress (Cohen d=0.69, 95% CI 0.17-1.21), anxiety (Cohen d=0.59, 95% CI 0.07-1.11), and stress (Cohen d=0.76, 95% CI 0.23-1.28). Time-by-group interactions for proportional reductions between groups over time were only significant after treatment and at the 1-month follow-up for the primary anxiety measure (P=.006). This study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible, and 95% (21/22) of the clients were satisfied with the treatment content and therapist support.

Conclusions

Findings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD and PPA symptoms to improve access to psychological treatments.

Trial Registration

ClinicalTrials.gov NCT04012580; https://clinicaltrials.gov/ct2/show/NCT04012580

Antidepressant medication use by patients accessing a national digital mental health service

BACKGROUND

Digital mental health services (DMHSs) provide psychological treatments via the internet or phone and are increasingly being offered as part of routine care. This study describes antidepressant (AD) medication use and treatment outcomes in a large sample of routine care patients accessing a DMHS.

METHODS

Patients completing an assessment with an Australia-wide DMHS (MindSpot Clinic) from 1st January to 31st December 2020 (n = 17,409) were asked about psychotropic medication use. Demographic characteristics and treatment outcomes on the PHQ-9 (depression), GAD-7 (anxiety), and K-10+ (general distress) were compared for patients taking an AD versus no AD. Treatment outcomes were also analyzed for a subgroup of patients reporting recent commencement of AD medication.

RESULTS

Almost one quarter of patients (4141/17409; 23.8%) reported taking an AD, mainly selective serotonin reuptake inhibitors (SSRIs). Patients taking ADs had more severe symptoms however effect sizes were large (Cohen's d's > 1.0). Patients recently commencing ADs had the highest baseline symptoms but showed greater symptom improvement at post-treatment and 3-month follow-up.

LIMITATIONS

Treatment trajectory was measured weekly using standardized scales that are sensitive to change, however they did not allow formal clinical diagnoses of depression and were subject to the effects of missing data. The observational design did not control for spontaneous recovery or for comorbid conditions that might influence recovery.

CONCLUSIONS

Despite these limitations, online treatment provided by a DMHS as part of routine care is acceptable and effective for patients reporting concurrent AD medication use.

A Randomized Factorial Trial of Internet-Delivered Cognitive Behaviour Therapy for Post-Secondary Students: Examining Motivational Interviewing and Booster Lessons (Preprint)

Background

Internet-delivered cognitive behavioral therapy (ICBT) can improve access to mental health care for students, although high attrition rates are concerning and little is known about long-term outcomes. Motivational interviewing (MI) exercises and booster lessons can improve engagement and outcomes in face-to-face cognitive behavioral therapy.

Objective

This study aimed to examine the use of pretreatment MI exercises and booster lessons in ICBT for postsecondary students.

Methods

In this factorial trial (factor 1: web-based MI before treatment; factor 2: self-guided booster lesson 1 month after treatment), 308 clients were randomized to 1 of 4 treatment conditions, with 277 (89.9%) clients starting treatment. All clients received a 5-week transdiagnostic ICBT course (the UniWellbeing course). Primary outcomes included changes in depression, anxiety, and perceived academic functioning from before treatment to after treatment and at the 1-month and 3-month follow-ups.

Results

Overall, 54% (150/277) of students completed treatment and reported large improvements in symptoms of depression and anxiety and small improvements in academic functioning after treatment, which were maintained at the 1-month and 3-month follow-ups. Pretreatment MI did not contribute to better treatment completion or engagement, although small between-group effects favored MI for reductions in depression (Cohen d=0.23) and anxiety (Cohen d=0.25) after treatment. Only 30.9% (43/139) of students randomized to one of the booster conditions accessed the booster. Overall, no main effects were found for the booster. Subanalyses revealed that clients who accessed the booster had larger decreases in depressive symptoms (Cohen d=0.31) at the 3-month follow-up. No interactions were found between MI and the booster.

Conclusions

Rather than offering MI before treatment, clients may experience more benefits from MI exercises later in ICBT when motivation wanes. The low uptake of the self-guided booster limited our conclusions regarding its effectiveness. Future research should examine offering a booster for a longer duration after treatment, with therapist support and a longer follow-up period.

Trial Registration

ClinicalTrials.gov NCT04264585; https://clinicaltrials.gov/ct2/show/NCT04264585

Somatosensory amplification moderates the efficacy of internet-delivered CBT for somatic symptom distress in emerging adults: Exploratory analysis of a randomized controlled trial

OBJECTIVE

While studies mainly provide positive evidence for the efficacy of internet-delivered cognitive-behavioral therapy (ICBT) for various persistent somatic symptoms, it remains largely unclear for whom these interventions work or not. This exploratory analysis aimed to identify moderators for the outcome between ICBT for somatic symptom distres and a waitlist control group (WL) in a vulnerable target group of emerging adults.

METHODS

Based on data from a randomized controlled trial on 156 university students with varying degrees of somatic symptom distress who were allocated to either an eight-week, therapist guided ICBT (iSOMA) or to the WL, we examined pretreatment demographic characteristics, health-related variables (e.g., somatic symptom duration), mental distress (e.g., depression, anxiety) and cognitive-emotional factors (emotional reactivity, somatosensory amplification) as candidate moderators of the outcome, somatic symptom distress (assessed by the Patient Health Questionnaire, PHQ-15) from pre- to posttreatment.

RESULTS

Somatosensory amplification (assessed by the Somatosensory Amplification Scale, SSAS) moderated the outcome in favor of iSOMA (B = -0.17, SE = 0.08, p = 0.031), i.e., higher pretreatment somatosensory amplification was associated with better outcome in the active compared to the control intervention. No significant moderation effects were found among demographic characteristics, health-related variables, or mental distress.

CONCLUSION

Our findings suggest that an internet-delivered CBT for somatic symptom distress should be preferred over no active treatment particularly in individuals with moderate to high levels of somatosensory amplification, which as a next step should be tested against further treatments and in clinical populations.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00014375).

A randomized factorial trial of internet-delivered cognitive behavioural therapy: An 8-week program with or without extended support and booster lesson

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

A Comparison of Self-Referral and Referral via Primary Care Providers, through Two Similar Digital Mental Health Services in Western Australia

Digital mental health services (DMHSs) deliver mental health information, assessment, and treatment, via the internet, telephone, or other digital channels. The current study compares two DMHSs operating in Western Australia (WA)-The Practitioner Online Referral System (PORTS) and MindSpot. Both provide telephone and online psychological services at no cost to patients or referrers. However, PORTS is accessed by patients via referral from health practitioners, and is designed to reach those who are financially, geographically, or otherwise disadvantaged. In contrast, MindSpot services are available to all Australian residents and patients can self-refer. This observational study compares characteristics and treatment outcomes for patients of PORTS and MindSpot in WA. Eligible patients were people who resided in WA and registered with either clinic from January 2019 to December 2020. Results showed that PORTS patients were more likely to be older, male, and unemployed. They were less likely to report a tertiary education and were more likely to live in areas with higher levels of socioeconomic disadvantage. Despite these differences, treatment outcomes were excellent for patients from both clinics. Results provide further evidence for the accessibility, acceptability, and effectiveness of DMHSs regardless of referral pathway or patient characteristics.

Adherence With Online Therapy vs Face-to-Face Therapy and With Online Therapy vs Care as Usual: Secondary Analysis of Two Randomized Controlled Trials

BACKGROUND

Adherence to internet-delivered interventions targeting mental health such as online psychotherapeutic aftercare is important for the intervention's impact. High dropout rates limit the impact and generalizability of findings. Baseline differences may be putting patients at risk for dropping out, making comparisons between online with face-to-face (F2F) therapy and care as usual (CAU) necessary to examine.

OBJECTIVE

This study investigated adherence to online, F2F, and CAU interventions as well as study dropout among these groups and the subjective evaluation of the therapeutic relationship. Sociodemographic, social-cognitive, and health-related variables were considered.

METHODS

In a randomized controlled trial, 6023 patients were recruited, and 300 completed the baseline measures (T1), 144 completed T2 (retention 44%-52%), and 95 completed T3 (retention 24%-36%). Sociodemographic variables (eg, age, gender, marital status, educational level), social-cognitive determinants (eg, self-efficacy, social support), health-related variables (eg, depressiveness), and expectation towards the treatment for patients assigned to online or F2F were measured at T1.

RESULTS

There were no significant differences between the groups regarding dropout rates (χ²₁=0.02-1.06, P≥.30). Regarding adherence to the treatment condition, the online group outperformed the F2F and CAU conditions (P≤.01), indicating that patients randomized into the F2F and CAU control groups were much more likely to show nonadherent behavior in comparison with the online therapy groups. Within study groups, gender differences were significant only in the CAU group at T2, with women being more likely to drop out. At T3, age and marital status were also only significant in the CAU group. Patients in the online therapy group were significantly more satisfied with their treatment than patients in the F2F group (P=.02; Eta²=.09). Relationship satisfaction and success satisfaction were equally high (P>.30; Eta²=.02). Combining all study groups, patients who reported lower depressiveness scores at T1 (T2: odds ratio [OR] 0.55, 95% CI 0.35-0.87; T3: OR 0.56, 95% CI 0.37-0.92) were more likely to be retained, and patients who had higher self-efficacy (T2: OR 0.57, 95% CI 0.37-0.89; T3: OR 0.52, 95% CI 0.32-0.85) were more likely to drop out at T2 and T3. Additionally, at T3, the lower social support that patients reported was related to a higher likelihood of remaining in the study (OR 0.68, 95% CI 0.48-0.96). Comparing the 3 intervention groups, positive expectation was significantly related with questionnaire completion at T2 and T3 after controlling for other variables (T2: OR 1.64, 95% CI 1.08-2.50; T3: OR 1.59, 95% CI 1.01-2.51).

CONCLUSIONS

While online interventions have many advantages over F2F variants such as saving time and effort to commute to F2F therapy, they also create difficulties for therapists and hinder their ability to adequately react to patients' challenges. Accordingly, patient characteristics that might put them at risk for dropping out or not adhering to the treatment plan should be considered in future research and practice. Online aftercare, as described in this research, should be provided more often to medical rehabilitation patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04989842; https://clinicaltrials.gov/ct2/show/NCT04989842.

Internet-delivered cognitive-behaviour therapy (ICBT) for obsessive-compulsive disorder when delivered as routine clinical care: A phase IV clinical trial

Cognitive-behaviour therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD), but many patients experience difficulty accessing this treatment. Internet-delivered CBT (ICBT) enhances access to CBT for individuals with OCD and has been shown to be efficacious in Phase I, II, and III clinical trials. However, there are fewer studies investigating ICBT for OCD in Phase IV clinical trials, which demonstrate the effectiveness of the intervention when provided as part of routine care. The aim of the present study was to report on the effectiveness of ICBT for OCD, using data from Australia's MindSpot Clinic, a federally funded treatment service that provides free ICBT to Australian adults with anxiety, depression, and pain conditions. A total of 225 MindSpot users (68 % female; Mage = 34.82; SD = 11.02) were included in the study. Within-group effect sizes at post-treatment on the Yale-Brown Obsessive-Compulsive Scale, indicated medium effect sizes (g = 0.6; 95 % CI: 0.5-0.7), increasing to large effects at three-month follow up (g = 0.9; 95 % CI: 0.8-1.0). Effects on secondary outcome measures including measures of depression, generalized anxiety, and psychological distress ranged from (g = 0.5-0.6) at post-treatment and (g = 0.5-0.7) at three-month follow up. Results from benchmarking analyses indicated that the results from routine care were significantly smaller than those found in a recent clinical trial using the same treatment protocol. The results indicate that ICBT delivered in real world settings is associated with meaningful improvements in OCD symptoms, however future research may wish to examine which patients respond best to this treatment approach and how to enhance outcomes.

Brief online motivational interviewing pre-treatment intervention for enhancing internet-delivered cognitive behaviour therapy: A randomized controlled trial

While the efficacy of therapist-guided internet-delivered cognitive behaviour therapy (iCBT) for anxiety and depression is well-established, a significant proportion of clients show little to no improvement with this approach. Given that motivational interviewing (MI) is found to enhance face-to-face treatment of anxiety, the current trial examined potential benefits of a brief online MI intervention prior to therapist-guided iCBT. Clients applying to transdiagnostic therapist-guided iCBT in routine care were randomly assigned to receive iCBT with (n = 231) or without (n = 249) the online MI pre-treatment. Clients rated motivation at screening and pre-iCBT and anxiety and depression at pre- and post-treatment and at 13- and 25-week follow-up after enrollment. Clients in the MI plus iCBT group made more motivational statements in their emails and were enrolled in the course for a greater number of days compared to clients who received iCBT only, but did not demonstrate higher motivation after completing the MI intervention or have higher course completion. Clients in both groups, at screening and pre-iCBT, reported high levels of motivation. No statistically significant group differences were found in the rate of primary symptom change over time, with both groups reporting large reductions in anxiety and depression pre- to post-treatment (Hedges' g range = 0.96-1.11). During follow-up, clients in the iCBT only group reported additional small reductions in anxiety, whereas clients in the MI plus iCBT group did not. The MI plus iCBT group also showed small increases in depression during follow-up, whereas improvement was sustained for the iCBT only group. It is concluded that online MI does not appear to enhance client outcomes when motivation at pre-treatment is high.