Motivation and Treatment Credibility Predicts Dropout, Treatment Adherence, and Clinical Outcomes in an Internet-Based Cognitive Behavioral Relaxation Program: A Randomized Controlled Trial

Predictors of Response to Cognitive Behavioral Therapy in Patients With Tinnitus

Importance

Clinical guidelines recommend cognitive behavioral therapy (CBT) as a treatment for tinnitus. However, patient response to CBT is variable, and currently, there are no known predictors of response to CBT treatment for tinnitus.

Objective

To identify the clinical predictors of patient response to CBT for treatment of tinnitus.

Design, Setting, and Participants

This was a secondary cohort analysis of a single-arm clinical study including adults with chronic bothersome tinnitus recruited from Washington University School of Medicine in St Louis (Missouri) from September 2019 to February 2023. Participants completed an 8-week group CBT program with a licensed clinical psychologist. Each week consisted of 2.5 hours of CBT, amounting to 20 hours of total CBT participation, primarily delivered through a virtual platform. Conjunctive consolidation was used to create a predictive classification system for response to CBT based on tinnitus bother and anxiety levels.

Main Outcome and Measure

Response to CBT was predefined as a 13-point or greater decrease in the Tinnitus Functional Index (TFI) survey score.

Results

The study sample included 88 adult patients (median [IQR] age, 59 [49-66] years; 47 [53%] females and 41 [47%] males) with chronic bothersome tinnitus, of whom 53 (60%) had at least 13-point decrease in TFI and were considered to be responders. In univariable and multivariable logistic regression analyses, high to moderate anxiety level and severe tinnitus bother were associated with treatment response (adjusted odds ratio: anxiety, 3.33; 95% CI, 0.90-12.30; tinnitus bother, 12.08; 95% CI, 1.48-98.35). The clinical stratification system showed good predictive and discriminative ability (χ2 for linear trend = 20.0; C statistic = 0.75; 95% CI, 0.65-0.85).

Conclusions and Relevance

The findings of this study show that assessment of bother and anxiety levels in patients with tinnitus may be useful for identifying those who are more likely to respond to CBT. Before incorporation into clinical practice, future research should externally validate this finding in a separate population.

Digital nature: Unveiling the impact and safety of FlowVR group intervention for depression in a feasibility trial

OBJECTIVE

This study addresses the limitations of existing interventions for depression, such as a deficit-oriented focus, overlooking the utilization of positive elements such as nature, and neglecting the incorporation of group effects. The present feasibility study examines FlowVR, a resource-oriented, nature-inspired virtual reality (VR)-based group therapy. Previously tested individually in a pilot study for non-clinical participants, FlowVR has demonstrated positive effects on depressive symptoms. This study assesses the impact and safety of FlowVR in a group setting within a clinical sample using a one-armed study design.

METHOD

Forty-two inpatients and day patients with depression were recruited. Before and after the FlowVR intervention period of 4 weeks (two sessions per week), depressive symptoms were assessed (Beck Depression Inventory-II; BDI). Symptomatology (i.e., depressive symptoms), depression-associated variables (i.e., self-efficacy), intervention-specific variables (feeling of flow), and VR-specific variables (simulator sickness) were assessed before and after each session.

RESULTS

Linear mixed effect models showed that symptomatology (depression, negative affect, current anxiety), depression-associated constructs (self-efficacy, motivation), and intervention-specific variables (flow) improved over the course of the sessions. No variable deteriorated more in one session compared to any other session. The lasso regression identified five potential predictors for the change in depression (BDI-II), yet these could not be validated in a subsequent linear regression analysis.

CONCLUSION

To conclude, FlowVR had the hypothesized positive impact over the course of the sessions, showing, for example, improvements in symptomatology. The sessions have demonstrated safety with no notable deteriorations. Therefore, FlowVR is deemed safe for clinical patients and group settings. However, further research is needed to explore predictors for the change in depression.

Motivational Variables as Moderating Effects of a Web-Based Mental Health Program for University Students: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Self-guided web-based interventions have the potential of addressing help-seeking barriers and symptoms common among university students, such as depression and anxiety. Unfortunately, self-guided interventions are also associated with less adherence, implicating motivation as a potential moderator for adherence and improvement for such interventions. Previous studies examining motivation as a moderator or predictor of improvement on web-based interventions have defined and measured motivation variably, producing conflicting results.

OBJECTIVE

This secondary analysis of data from a randomized controlled trial aimed to examine constructs of motivation as moderators of improvement for a self-guided 8-week web-based intervention in university students (N=1607).

METHODS

Tested moderators included internal motivation, external motivation, and confidence in treatment derived from the Treatment Motivation Questionnaire. The primary outcome was an improvement in depression and anxiety measured by the Depression Anxiety Stress Scale-21.

RESULTS

Piecewise linear mixed effects models showed that internal motivation significantly moderated symptom change for the intervention group (t1504=-2.94; P=.003) at average and high (+1 SD) motivation levels (t1507=-2.28; P=.02 and t1507=-4.05; P<.001, respectively). Significant results remained even after controlling for baseline severity. The results showed that confidence in treatment did not significantly moderate symptom change for the intervention group (t1504=1.44; P=.15). In this sample, only internal motivation was positively correlated with service initiation, intervention adherence, and intervention satisfaction.

CONCLUSIONS

The combination of a web-based intervention and high or moderate internal motivation resulted in greater improvement in the total Depression Anxiety Stress Scale-21 score. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. The results suggest that the combination of a web-based intervention and high or moderate internal motivation results in greater improvement. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. To better understand the moderating role of internal motivation, future research is encouraged to replicate these findings in diverse samples as well as to examine related constructs such as baseline severity and adherence. Understanding these characteristics informs treatment strategies to maximize adherence and improvement when developing web-based interventions as well as allows services to be targeted to individuals likely to benefit from such interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/study/NCT04361045.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Not applicable.

Motivation to change predicts college students' utilization of self-help resources

Background: Stress and mental health difficulties are common burdens on college students. College counseling centers have been overrun by demand. Thus, self-help interventions may offer a promising alternative to traditional college counseling services. Methods: The current study examined the influence of perceived stress, motivation to change, and self-efficacy beliefs on college students' use of self-help resources, to determine whether these factors would predict follow-up with self-help recommendations. Results: Results of stepwise linear regression models suggest that perceived stress and self-efficacy did not predict self-help resource utilization. Different types of self-help recommendations did not predict different levels of follow-up. However, motivation to change was a significant predictor college students' self-help resource use, and this variable was particularly important when self-help recommendations were less structured. Conclusions: These findings can help to predict which college students are likely to make use of self-help resources, and inform targeted individual treatment.

Abbreviated Dialectical Behavior Therapy Virtual Skills Group for Caregivers of Adolescents: An Exploratory Study of Service User and Clinical Outcomes

Prior work emphasizes involving caregivers in youth mental health services. To support youth with emotion dysregulation, dialectical behavior therapy for adolescents (DBT-A) includes a multi-family skills group, wherein adolescents and caregivers learn skills together. However, limited work has examined the impact of caregiver involvement within DBT-A. The current study examines outcomes of two caregiver-only DBT-A skills groups adapted for abbreviated telehealth delivery. We report on caregivers' (N = 11, 100% mothers, 55% Hispanic) service user outcomes (e.g. self-efficacy at skill usage, group cohesion, therapeutic alliance) and clinical outcomes (i.e. their own emotion functioning, criticism, responses to their adolescent's negative emotions). Results indicate caregiver-only groups were feasible and acceptable, and suggest preliminary efficacy, including improvements in caregiver emotion functioning, distress during interactions with their adolescents, and adolescent-reported criticism. Caregivers also reported reductions in unsupportive responses with their adolescents. Overall, while we caution interpretation due to a small sample size, findings support the preliminary feasibility and efficacy of modifying caregiver participation in DBT-A to be less time-consuming and administered via telehealth.

An Investigation of Further Strategies to Optimize Early Treatment Gains in Brief Therapies for Insomnia

OBJECTIVES

Identifying those who are most (and least) likely to benefit from a stepped-care approach to cognitive behavioral therapy for insomnia (CBT-I) increases access to insomnia therapies while minimizing resource consumption. The present study investigates non-targeted factors in a single-session of CBT-I that may act as barriers to early response and remission.

METHODS

Participants (N = 303) received four sessions of CBT-I and completed measures of subjective insomnia severity, fatigue, sleep-related beliefs, treatment expectations, and sleep diaries. Subjective insomnia severity and sleep diaries were completed between each treatment session. Early response was defined as a 50% reduction in Insomnia Severity Index (ISI) scores and early remission was defined by < 10 on the ISI after the first session.

RESULTS

A single-session of CBT-I significantly reduced subjective insomnia severity scores and diary total wake time. Logistic regression models indicated that lower baseline fatigue was associated with increased odds of early remission (B = -.05, p = .02), and lower subjective insomnia severity (B = -.13, p = .049). Only fatigue was a significant predictor of early treatment response (B = -.06, p = .003).

CONCLUSIONS

Fatigue appeared to be an important construct that dictates early changes in perceived insomnia severity. Beliefs about the relationship between sleep and daytime performance may hinder perceived improvements in insomnia symptoms. Incorporating fatigue management strategies and psychoeducation about the relationship between sleep and fatigue may target non-early responders. Future research would benefit from further profiling potential early insomnia responders/remitters.

Patient motivation and adherence in metacognitive therapy for major depressive disorder: an observational study

The aim of this observational study was to examine the predictive and discriminant validity of patient motivation and adherence in metacognitive therapy (MCT) for depression. Motivational development for recovered- and non-recovered patients was also investigated. Motivation in sessions 1, 4, and 7 was measured using the Motivational Interviewing Skill Code 2.5 (MISC) in a 10-session trial of MCT for depression (N = 37). Adherence was assessed with the CBT compliance measure in session 7. The Beck Depression Inventory measured treatment outcome at 3-year follow-up. Recovered patients developed significantly more change talk and taking steps, and less sustain talk, as therapy progressed, compared to non-recovered patients. Evidence of the predictive validity of motivation in sessions 1 and 4 was limited. Higher sustain talk and taking steps in session 7 were significant predictors of more and less depressive symptoms, respectively. There was a moderate-strong correlation between motivation and adherence. The results confirm the predictive value of MISC in sessions 7 of MCT for depression, and establish differential motivational development between recovered and non-recovered patients. Subsequent research should clarify the discriminant validity and temporal relationships between motivation, adherence, and other clinical variables.

Development and Psychometric Evaluation of the Motivation for Healing Scale in Patients with Cancer

Introduction

This study was conducted to develop and validate a Motivation for Healing Scale (MHS) in Cancer.

Methods

in this methodological study, the MHS draft was developed based on the approach of Waltz and colleagues using existing scales and concept analysis. The psychometric features, including face validity (qualitative and quantitative), content validity (qualitative and quantitative), structural validity (exploratory and confirmatory factors), and construct validity (convergent and discriminant validity) were assessed. Finally, the reliability was evaluated using internal consistency, and stability.

Results

Based on the results of the qualitative phase, an initial item pool was generated with 55 items, Exploratory and confirmatory factor analyses were performed on the data collected from 404 patients. 25 Items were excluded during the psychometric evaluation phases. Reliability assessment and internal consistency assessment revealed that Cronbach's alpha value of the 25-item MHS was 0.912. The results of intraclass correlation coefficient (0.93, 95% CI: 0.86- 0.96) showed the stability was strong.

Conclution

The 25-item MHS is a valid and reliable scale for the assessment of motivation for healing in patients with cancer.

Nerva, a mobile application of gut-directed hypnotherapy for irritable bowel syndrome: User characteristics, patterns of use, and predictors of persistence

Background

Hypnotic intervention for irritable bowel syndrome (IBS), or gut-directed hypnotherapy (GDH), is an effective treatment for improving IBS symptoms with minimal burden and risk in delivery to patients. The Nerva app, developed by Mindset Health, shows promise for dissemination and implementation of evidence-based GDH intervention for IBS.

Objectives

This study aimed to describe the demographic and clinical characteristics of Nerva app users, examine usage patterns, and explore potential factors associated with Nerva app usage.

Methods

A retrospective analysis of data was conducted of 14,898 individuals who downloaded and used the Nerva app between January 2022 and September 2022. Descriptive statistics and Chi-square tests of independence were calculated to examine demographic/clinical characteristics, usage patterns, and their associations to program persistence. Simple linear regression models were used for correlations of GI symptoms severity scores to user persistence.

Results

Users predominantly identified as female (77.2%; n = 11,503) and had a mean age of 38.59 years old (SD = 13.38). Thirty-one percent of users persisted with the program, and a small statistically significant association was found between Nerva app program persistence and age, χ2 (6, N = 6745) = 164.82, p < 0.001, V = .16.

Conclusions

The present study found promising adherence rates for the Nerva app program within the first six weeks of use. Statistics in prevalence estimates of IBS agree with previous literature and significant associations were found between user/clinical characteristics and Nerva app program persistence.

A randomized controlled pilot trial of brief online mindfulness training in young drivers

OBJECTIVE

Driver distraction contributes to fatal and injury crashes in young drivers. Mind wandering (MW) is a covert form of distraction involving task-unrelated thoughts. Brief online mindfulness training (MT) may reduce unsafe driving by enhancing recognition (meta-awareness) of MW and reducing its occurrence. This pilot trial tested these proposed mechanisms of MT and explored its specificity of action, effects on driving behaviour in simulation, as well as intervention adherence and acceptability in young drivers.

METHODS

A pre-post (T1, T2), randomized, active placebo-controlled, double-blinded design was used. Twenty-six drivers, aged 21-25, received either brief online MT (experimental) or progressive muscle relaxation (PMR, control) over 4-6 days. A custom website blindly conducted randomization, delivered interventions, administered questionnaires, and tracked adherence. At T1 and T2, a simulator measured driving behaviour while participants indicated MW whenever they recognized it, to assess meta-awareness, and when prompted by a thought-probe, to assess overall MW.

RESULTS

MT reduced MW while driving in simulation. The MT group reported higher state mindfulness following sessions. Motivation did not account for MW or mindfulness results. MT and meta-awareness were associated with more focus-related steering behaviour. Intervention groups did not significantly differ in adherence or attrition. No severe adverse effects were reported, but MT participants reported more difficulty following intervention instructions.

CONCLUSION

Results support a plausible mechanism of MT for reducing MW-related crash risk (i.e., reduction of MW) in young drivers. This preliminary evidence, alongside promising online adherence and acceptability results, warrants definitive efficacy and effectiveness trials of online MT.

Patient engagement as a core element of translating clinical evidence into practice- application of the COM-B model behaviour change model

BACKGROUND

The results of rehabilitation trials are often not fully attained when the intervention is implemented beyond the initial trial. One of the key reasons is that a patients' ability and/or capacity to take part in their own healthcare is not considered in the trial design yet has significant impact on the outcomes during the implementation phase.

BODY OF TEXT

We propose a shift from a therapist-focus to patient-focus in trial design, through addressing patient engagement as a core consideration in trials. We argue that engaging patients in any rehabilitation program is a process of behavioural change. Exercise prescription is used as an example to illustrate how the Behaviour Change Wheel can be applied to analyse barriers and facilitators associated with patients' capabilities, opportunities and motivations in integrating trial interventions into their daily life. We propose a framework to assist in this shift.

CONCLUSION

A core part of implementing rehabilitation interventions at the primary care level requires patient engagement. Related aspects of interventions should be identified and assessed using the COM-B model at the outset of trial design to ensure that the results are realistic, meaningful and transferable, so as to enable real impact.

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

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

A Guided, Internet-Based Stress Management Intervention for University Students With High Levels of Stress: Feasibility and Acceptability Study

BACKGROUND

Transitioning to adulthood and challenges in university life can result in increased stress levels among university students. Chronic and severe stress is associated with deleterious psychological and physiological effects. Digital interventions could succeed in approaching and helping university students who might be at risk; however, the experiences of students with internet-based stress management interventions are insufficiently understood.

OBJECTIVE

This study aims to explore the feasibility; acceptability; and changes in perceived stress, depressive symptoms, and quality of life from baseline to posttest assessment of a 5-session, internet-based stress management intervention guided by an e-coach, developed for university students experiencing high levels of stress.

METHODS

A single-arm study was conducted. Students were recruited from different channels, mainly from a web survey. Students were eligible if they (1) scored ≥20 on the Perceived Stress Scale-10, (2) were aged ≥18 years, and (3) were studying at one of the participating universities. Feasibility and acceptability of the intervention were investigated using several indications, including satisfaction (Client Satisfaction Questionnaire-8) and usability (System Usability Scale-10). We also investigated the indicators of intervention adherence using use metrics (eg, the number of completed sessions). Our secondary goal was to explore the changes in perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9), and quality of life (EQ-5D-5L scale) from baseline to posttest assessment. In addition, we conducted semistructured interviews with intervention completers and noncompleters to understand user experiences in depth. For all primary outcomes, descriptive statistics were calculated. Changes from baseline to posttest assessment were examined using 2-tailed paired sample t tests or the Wilcoxon signed rank test. Qualitative data were analyzed using thematic analysis.

RESULTS

Of 436 eligible students, 307 (70.4%) students started using the intervention. Overall, 25.7% (79/307) completed the core sessions (ie, sessions 1-3) and posttest assessment. A substantial proportion of the students (228/307, 74.3%) did not complete the core sessions or the posttest assessment. Students who completed the core sessions reported high satisfaction (mean 25.78, SD 3.30) and high usability of the intervention (mean 86.01, SD 10.25). Moreover, this group showed large reductions in perceived stress (Cohen d=0.80) and moderate improvements in depression score (Cohen d=0.47) and quality of life (Cohen d=-0.35) from baseline to posttest assessment. Qualitative findings highlight that several personal and intervention-related factors play a role in user experience.

CONCLUSIONS

The internet-based stress management intervention seems to be feasible, acceptable, and possibly effective for some university students with elevated stress levels. However, given the high dropout rate and qualitative findings, several adjustments in the content and features of the intervention are needed to maximize the user experience and the impact of the intervention.

TRIAL REGISTRATION

Netherlands Trial Register 8686; https://onderzoekmetmensen.nl/nl/trial/20889.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2021.100369.

A Faith-Based Intervention to Address Social Isolation and Loneliness in Older Adults

ABSTRACT

The goal of this quality improvement project was to determine if virtually offered faith-based resources for socially isolated older adults could reduce loneliness and improve quality of life. A nurse-developed program of virtual spiritual and religious interventions, including mindfulness, prayer, Scripture meditation, gratitude practices, and online church services, was offered by local ministers to older adults at risk of social isolation or loneliness. A sample of 16 adults over age 55 from local communities participated in the 12-week intervention and follow-up. The intervention resulted in a significant decrease in perception of social loneliness and improved physical health quality of life.

Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting

LAY ABSTRACT

Autistic adults are often stressed and feel depressed or anxious. However, mental health programs that are suited for autistic adults are few. Acceptance and commitment therapy is a psychotherapy method that seems to help people feel better, although not thoroughly evaluated in autistic individuals. In this study, 20 autistic adults had 14 weeks of acceptance and commitment therapy group treatment suited for autism (NeuroACT), while 19 autistic adults had ordinary care. The acceptance and commitment therapy group treatment program seemed logical and reasonable to the participants. Also, when comparing the participants in the NeuroACT group with those in the ordinary care group, the NeuroACT participants reported less stress and higher quality of life. Compared to the ordinary care group, they could also manage distressing thoughts better, perceived themselves as more flexible, and did not avoid stressful situations as much as before. However, there was no significant difference between the groups in depression, anxiety, sleep problems, social aspects of autism, everyday functioning, or executive challenges. Slightly more NeuroACT participants did not finish the treatment than ordinary care participants. In conclusion, the NeuroACT program may be a treatment for autistic adults who feel stressed and have reduced quality of life. More studies are needed to see how helpful the NeuroACT program is for autistic adults.

Developing a Psychological Intervention for Decreasing Bedtime Procrastination: The BED-PRO Study

INTRODUCTION

Bedtime Procrastination (BP) is defined as the behavior of going to bed later than intended, without having external reasons for doing so. Previous studies have shown that BP has a negative effect on sleep and health, emphasizing the need to develop interventions to decrease BP. This intervention development study is a proof-of-concept study for a psychological intervention designed for decreasing bedtime procrastination, namely BED-PRO.

MATERIAL AND METHOD

The intervention was developed based on behavioral modification principles and motivational interviewing techniques. The final intervention was a weekly three-session intervention, with one additional booster call. Twenty individuals with high BP participated in the study, and data was collected for pre- and post-intervention, and one-month follow-up. Individuals completed the Bedtime Procrastination Scale, Epworth Sleepiness Scale, Fatigue Severity Scale, Morningness-Eveningness Questionnaire, Insomnia Severity Index, and a sleep diary.

RESULT

Significant changes were found for BPS scores, bedtime procrastination duration (Δ51 mins, 63.8% reduction compared to baseline), wake after sleep onset, sleep efficiency and feeling refreshed upon awakening measured by sleep diaries following the intervention. In addition, changes in BPS, ISI, and ESS scores, wake after sleep onset, sleep efficiency and feeling refreshed upon awakening were maintained or continued to improve at 1-month follow-up.

CONCLUSION

This study verified the feasibility and acceptability of the BED-PRO intervention and the potential for being the first intervention to target bedtime procrastination. Considering the research about negative implications of BP, we expect that this intervention could be a step forward in considering BP as a serious health behavior.

Overall and Differential Attrition in Mindfulness-Based Interventions: A Meta-Analysis

Objectives

Attrition is very common in longitudinal research, including randomized controlled trials (RCTs) testing psychological interventions. Establishing rates and predictors of attrition in mindfulness-based interventions (MBIs) can assist clinical trialists and intervention developers. Differential attrition in RCTs that compared MBIs with structure and intensity matched active control conditions also provides an objective metric of relative treatment acceptability.

Methods

We aimed to evaluate rates and predictors of overall and differential attrition in RCTs of MBIs compared with matched active control conditions. Attrition was operationalized as loss to follow-up at post-test. Six online databases were searched.

Results

Across 114 studies (n = 11,288), weighted mean attrition rate was 19.1% (95% CI [.16, .22]) in MBIs and 18.6% ([.16, .21]) in control conditions. In the primary model, no significant difference was found in attrition between MBIs and controls (i.e., differential attrition; odds ratio [OR] = 1.05, [0.92, 1.19]). However, in sensitivity analyses with trim-and-fill adjustment, without outliers, and when using different estimation methods (Peto and Mantel-Haenszel), MBIs yielded slightly higher attrition (ORs = 1.10 to 1.25, ps < .050). Despite testing numerous moderators of overall and differential attrition, very few significant predictors emerged.

Conclusions

Results support efforts to increase the acceptability of MBIs, active controls, and/or RCTs, and highlight the possibility that for some individuals, MBIs may be less acceptable than alternative interventions. Further research including individual patient data meta-analysis is warranted to identify predictors of attrition and to characterize instances where MBIs may or may not be recommended. Meta-Analysis Review Registration: Open Science Framework (https://osf.io/c3u7a/).

Age, Motivation, and Emotion Regulation Skills Predict Treatment Outcome in an Internet-Based Self-Help Intervention for COVID-19 Related Psychological Distress

Introduction

First evidence suggests that internet-based self-help interventions effectively reduce COVID-19 related psychological distress. However, it is yet unclear which participant characteristics are associated with better treatment outcomes. Therefore, we conducted secondary analyses on data from a randomized controlled trial investigating the efficacy of a 3-week internet-based self-help intervention for COVID-19 related psychological distress. In this exploratory analysis, we examined several predictors ranging from sociodemographic variables to psychological distress, resource-related, and treatment-related variables. This includes, for example, age, motivation, and emotion regulation skills. Treatment outcomes were defined as post-treatment depressive symptoms and post-treatment resilience.

Methods

In a total of 107 participants with at least mild depressive symptoms, possible predictor variables and treatment outcomes were assessed using self-report measures. For example, emotion regulation skills were assessed by the Self-report measure for the assessment of emotion regulation skills. In a first step, we performed a separate linear regression analysis for each potential predictor. In a second step, predictors meeting a significant threshold of p < 0.05 were entered in linear multiple regression models. Baseline scores of the respective outcome measure were controlled for.

Results

The mean age of the participants was 40.36 years (SD = 14.59, range = 18–81 years) with the majority being female (n = 87, 81.3%). Younger age predicted lower post-treatment depressive symptoms. Additionally, higher motivation to use the intervention and better pre-treatment emotion regulation skills predicted higher post-treatment resilience.

Conclusion

The current study provides preliminary evidence regarding the relationship between participant characteristics and treatment outcome in internet-based self-help interventions for COVID-19 related distress. Our results suggest that under the circumstances surrounding COVID-19 such interventions might be particularly beneficial for young adults regarding depressive symptoms. Moreover, focusing on participants' existing strengths might be a promising approach to promote resilience through internet-based self-help interventions. However, since this was an exploratory analysis in an uncontrolled setting, further studies are needed to draw firm conclusions about the relationship of participant characteristics and treatment outcome in internet-based self-help interventions for COVID-19 related psychological distress.

Goal language is associated with attrition and weight loss on a digital program: Observational study

Behavioral weight loss reduces risk of weight-related health complications. Outcomes of behavioral weight loss programs include attrition and weight loss. There is reason to believe that individuals' written language on a weight management program may be associated with outcomes. Exploring associations between written language and these outcomes could potentially inform future efforts towards real-time automated identification of moments or individuals at high risk of suboptimal outcomes. Thus, in the first study of its kind, we explored whether individuals' written language in actual use of a program (i.e., outside of a controlled trial) is associated with attrition and weight loss. We examined two types of language: goal setting (i.e., language used in setting a goal at the start of the program) and goal striving (i.e., language used in conversations with a coach about the process of striving for goals) and whether they are associated with attrition and weight loss on a mobile weight management program. We used the most established automated text analysis program, Linguistic Inquiry Word Count (LIWC), to retrospectively analyze transcripts extracted from the program database. The strongest effects emerged for goal striving language. In striving for goals, psychologically distanced language was associated with more weight loss and less attrition, while psychologically immediate language was associated with less weight loss and higher attrition. Our results highlight the potential importance of distanced and immediate language in understanding outcomes like attrition and weight loss. These results, generated from real-world language, attrition, and weight loss (i.e., from individuals' natural usage of the program), have important implications for how future work can better understand outcomes, especially in real-world settings.

A self-guided and monitored digital problem-solving intervention for patients with symptoms of depression or anxiety on the waiting list for treatment in routine psychiatric care: feasibility study

BACKGROUND

There is often a waiting period for people who seek psychiatric treatment for depression or anxiety. As this delay risks worsening symptoms, an alternative could be to provide an intervention that requires minimal resources during the waiting period.

AIMS

The aim was to investigate if a digital problem-solving intervention delivered in a self-guided format with automated features is feasible to provide for patients on the waiting list in routine psychiatric care.

METHOD

A total of 12 patients with symptoms of depression or anxiety on the waiting list for treatment in routine psychiatric care were given access to a self-guided and monitored digital problem-solving intervention over 4 weeks. Primary outcome measures were treatment credibility and usability. Secondary outcome measures were behavioural engagement, symptoms of depression and anxiety, and negative effects.

RESULTS

A majority of participants rated the intervention as both credible and usable. The intervention was used at least once by nine out of 12 individuals, with an average of 11 logins. The participants did, on average, initiate 2.8 problem-solving attempts and 10.1 solutions. A few participants reached a clinically relevant symptom improvement of depression and anxiety. No serious negative effects were reported.

CONCLUSIONS

The credibility and usability of the intervention was perceived as good, and the behavioural engagement with the intervention was deemed sufficient compared with similar self-guided interventions. A self-guided and monitored digital problem-solving intervention may be a beneficial option for patients waiting for or receiving treatment in routine psychiatric care, and should be further evaluated.

Predictors of Treatment Response to an Internet-Delivered Intervention Targeting Residual Cognitive Symptoms After Major Depressive Disorder

OBJECTIVE

Residual cognitive symptoms after depression are common and associated with reduced daily life functioning and an increased risk of depression relapse. There is a lack of knowledge on treatments targeting residual cognitive symptoms after major depressive disorder (MDD), including the factors associated with treatment response. The aim of the current study is to explore factors of treatment response to a guided internet-delivered intervention for former depressed adults experiencing residual cognitive symptoms.

METHOD

Forty-three former depressed adults with residual cognitive symptoms were included. Linear mixed model analyses were used to investigate the impact of pre-treatment demographic-, illness, and symptom variables, and therapy process variables, such as credibility, expectancy, and user behavior, on reduction in residual cognitive symptoms from pre-treatment to 6-month follow-up.

RESULTS

Having had MDD for a year or less predicted more reductions in residual cognitive symptoms from pre- to 6-month follow-up. Higher levels of perceived treatment credibility and expectancy evaluated in the early course of treatment did also predict a positive treatment response. No demographic-, symptom-variables, previous number of episodes with MDD, and user behavior were associated with change in residual cognitive symptoms.

CONCLUSION

This study suggests that individuals with shorter duration of previous depressions might have larger reductions in residual cognitive symptoms at 6-month follow-up compared to those with a longer duration of depression. Treatment credibility and expectancy also predicted treatment response and effort should also be made to ensure interventions credibility. Results should be interpreted with caution due to the study having a low sample size. Further investigation of predictors should be conducted in a full scale randomized controlled trial.

An analysis of patient motivation for seeking online treatment for binge eating disorder-A mixed methods study combining systematic text condensation with sentiment analysis

OBJECTIVE

Online treatment for binge eating disorder (BED) is an easily available option for treatment compared to most standard treatment procedures. However, little is known about how motivation types characterize this population and how these impact treatment adherence and effect in an online setting. Therefore, we aimed to investigate a sample of written motivation statements from BED patients, to learn more about how treatment and online treatment in particular, presents in this population.

METHODS

Using self-determination theory in a mixed methods context, we investigated which types of motivation were prevalent in our sample, how this was connected with patient sentiment, and how these constructs influence treatment and adherence.

RESULTS

Contrary to what most current literature suggests, we found that in our sample (n = 148), motivation type was not connected with treatment outcome. We did find a strong association between sentiment scores and motivation types, indicating the model is apt at detecting effects. We found that when comparing an adult and young adult population, they did not differ in motivation type and the treatment was equally effective in young adults and adults. In the sentiment scores there was a difference between sentiment score and adherence in the young adult group, as the more positive the young adults were, the less likely they were to complete the program.

DISCUSSION

Because motivation type does not influence online treatment to the same degree as it would in face-to-face treatment it indicates that the typical barriers to treatment may be less crucial in an online setting. This should be considered during intake; as less motivated patients may be able to adhere better to online treatment, because the latter imposes fewer barriers of the kind that only strong motivation can overcome. The fact that motivation type and sentiment score of the written texts are strongly associated, indicate a potential for automated models to detect motivation based on sentiment.

Technology-supported strategies for promoting user engagement with digital mental health interventions: A systematic review

Background

Although digital mental health interventions (DMHIs) offer a potential solution for increasing access to mental health treatment, their integration into real-world settings has been slow. A key reason for this is poor user engagement. A growing number of studies evaluating strategies for promoting engagement with DMHIs means that a review of the literature is now warranted. This systematic review is the first to synthesise evidence on technology-supported strategies for promoting engagement with DMHIs.

Methods

MEDLINE, EmbASE, PsycINFO and PubMed databases were searched from 1 January 1995 to 1 October 2021. Experimental or quasi-experimental studies examining the effect of technology-supported engagement strategies deployed alongside DMHIs were included, as were secondary analyses of such studies. Title and abstract screening, full-text coding and quality assessment were performed independently by two authors. Narrative synthesis was used to summarise findings from the included studies.

Results

24 studies (10,266 participants) were included. Engagement strategies ranged from reminders, coaching, personalised information and peer support. Most strategies were disseminated once a week, usually via email or telephone. There was some empirical support for the efficacy of technology-based strategies towards promoting engagement. However, findings were mixed regardless of strategy type or study aim.

Conclusions

Technology-supported strategies appear to increase engagement with DMHIs; however, their efficacy varies widely by strategy type. Future research should involve end-users in the development and evaluation of these strategies to develop a more cohesive set of strategies that are acceptable and effective for target audiences, and explore the mechanism(s) through which such strategies promote engagement.

Effect of online counselling on emotional outcomes during the COVID‐19 pandemic: An innovative group intervention for university students using the Brain Wave Modulation Technique

Young people's mental health problems are a matter of concern during the COVID‐19 pandemic. Counselling services for university students by means of telemental support can help them to deal with psychological issues that they may be facing due to the pandemic. The present study investigated the effects of four once‐weekly online counselling sessions based on a mind‐body technique (the Brain Wave Modulation Technique; BWM‐T) on enhancing positive affect and on reducing negative affect and anxiety in a sample of 54 university students (96.3% females; M_age = 21.31 years, SD = 2.09). An experimental design was conducted: the participants were randomly assigned to the intervention group, which received 15 min of a guided online BWM‐T session, or to the control group, which watched a 15‐min video on how to sustain their psychological well‐being. The results of a two‐factor mixed‐design analysis of variance (ANOVA) showed that the participants in the intervention group reported a significant increase in positive affect and a decrease in negative affect over time compared to those in the control group. They also reported a slight decrease in state anxiety compared to the control group, although this was just short of statistical significance. The information provided by this study, regarding emotional outcomes among university students after four brief online counselling sessions, suggests that such interventions could be an effective and sustainable way to reinforce young people's mental health during the COVID‐19 pandemic, as well as later in their university careers and adult lives.

Insight and the number of completed modules predict a reduction of positive symptoms in an Internet-based intervention for people with psychosis

Emerging evidence suggests that Internet-based interventions for people with psychosis (ICBTp) are feasible and efficacious. However, predictors of adherence and treatment outcomes are largely unknown. To narrow this research gap, we conducted secondary analyses on data from a randomized controlled trial, which evaluated an eight-week ICBTp intervention targeting topics, such as voice hearing, mindfulness, and others. In n = 100 participants with psychosis, we aimed at identifying sociodemographic, psychopathological, and treatment-related predictor variables of post-treatment symptoms and adherence (i.e., at least four completed modules). We followed a two-stage approach. First, we conducted regression analyses to examine the effect of single candidate predictors on post-treatment symptoms as well as adherence. Subsequently, we selected variables that met a significance threshold of p < .1 and entered them into linear and logistic multiple regression models. Whereas no variable was able to predict adherence, the number of completed modules was negatively associated with self-reported delusion severity at post-treatment. Additionally, higher pre-treatment insight predicted fewer hallucinations after treatment. Because this was one of the first studies to investigate predictors in ICBTp, more research is needed to customize future interventions to the needs of users.

Optimizing Coaching During Web-Based Relationship Education for Low-Income Couples: Protocol for Precision Medicine Research

Background

In-person relationship education classes funded by the federal government tend to experience relatively high attrition rates and have only a limited effect on relationships. In contrast, low-income couples tend to report meaningful gains from web-based relationship education when provided with individualized coach contact. However, little is known about the method and intensity of practitioner contact that a couple requires to complete the web-based program and receive the intended benefit.

Objective

The aim of this study is to use within-group models to create an algorithm to assign future couples to different programs and levels of coach contact, identify the most powerful predictors of treatment adherence and gains in relationship satisfaction within 3 different levels of coaching, and examine the most powerful predictors of treatment adherence and gains in relationship satisfaction among the 3 levels of coach contact.

Methods

To accomplish these goals, this project intends to use data from a web-based Sequential Multiple Assignment Randomized Trial of the OurRelationship and web-based Prevention and Relationship Enhancement programs, in which the method and type of coach contact were randomly varied across 1248 couples (2496 individuals), with the hope of advancing theory in this area and generating accurate predictions. This study was funded by the US Department of Health and Human Services, Administration for Children and Families (grant number 90PD0309).

Results

Data collection from the Sequential Multiple Assignment Randomized Trial of the OurRelationship and web-based Prevention and Relationship Enhancement Program was completed in October of 2020.

Conclusions

Some of the direct benefits of this study include benefits to social services program administrators, tailoring of more effective relationship education, and effective delivery of evidence- and web-based relationship health interventions.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33047

The effect of depression and anxiety symptom severity on clinical outcomes and app use in digital mental health treatments: Meta-regression of three trials

A large number of trials have consistently shown that guided digital mental health treatments (DMHTs) are effective for depression and anxiety. As DMHTs are adopted by healthcare organizations, payers, and employers, they are often considered most appropriate for people with mild-to-moderate levels of symptom severity. Thus, the aim of this study was to examine the effects of symptom severity on depression and anxiety outcomes and app use across three trials of a guided DMHT, IntelliCare. Participants were categorized into mild, moderate, moderately severe, and severe symptom severity groups on depression and anxiety. All symptom severity groups showed significant reductions in depression and anxiety in a clear ordinal pattern, with the mild symptom severity group showing the smallest changes and the severe symptom group showing the largest improvements. Those with the lowest levels of educational attainment showed the largest symptom improvement. Baseline symptom severity was not significantly related to app use. App use was significantly related to depression and anxiety outcomes. These findings suggest that depression and anxiety symptom severity is not useful in determining who should be referred to a guided DMHT.

The Influence of Human Support on the Effectiveness of Digital Mental Health Promotion Interventions for the General Population

Mental wellbeing amongst the general population is languishing—exacerbated by the Coronavirus Disease 2019 (COVID-19) pandemic. Digital mental health promotion interventions, that improve mental health literacy and encourage adoption of evidence-informed practical strategies are essential. However, attrition and non-adherence are problematic in digital interventions. Human support is often applied as an antidote; yet, there is a paucity of randomized trials that compare different human support conditions amongst general population cohorts. Limited trials generally indicate that human support has little influence on adherence or outcomes in DMHPIs. However, providing participants autonomy to self-select automated support options may enhance motivation and adherence.

Observing the Working Alliance in Videoconferencing Psychotherapy for Alcohol Addiction: Reliability and Validity of the Working Alliance Inventory Short Revised Observer

The coronavirus disease-2019 (COVID-19) pandemic has affected the mental health and alcohol consumption of individuals. Videoconferencing psychotherapy has become a fundamental mode of treatment for people with alcohol use disorders. However, there are still doubts about its effectiveness and the therapeutic relationship. The working alliance is considered a foundation of effective practice in cognitive behavioral therapy (CBT). Observer measurements of the working alliance have demonstrated reliability and meaningful associations with the reduction of symptoms. However, translations of instruments to evaluate the working alliance and examine its construct have not previously been conducted for online psychotherapy for alcohol addiction. This study aimed for the cross-cultural adaptation of the Working Alliance Inventory-Short Form-Observer (WAI-SR-O) for Brazil and the evaluation of its reliability and evidence of its validity in videoconferencing psychotherapy for alcoholism. The WAI-SR-O was applied by pairs of observers for the evaluation of the working alliance in 19 recorded sessions of videoconferencing psychotherapy of 10 clients with a diagnosis of alcohol addiction. The sessions were also evaluated by the therapist (WAI-T) and client (WAI-C). The WAI-SR-O shows a moderate inter-rater intraclass correlation coefficient (ICC = 0.67) for the general scale, higher ICC for the goals and bond subscales, and a moderate value for the task subscale. The internal consistency was good (a = 0.86). The results show low but significant correlations among the goals and bond subscales of the WAI-SR-O and the general, goals, and bond scales of the WAI-T. No correlations were found with the WAI-C. As the literature points out, the client, therapist, and observer versions of the WAI evaluated the alliance differently, requiring further study. The WAI-SR-O proved to be a reliable and valid measurement for the evaluation of the working alliance in videoconferencing psychotherapy for alcohol addiction, becoming an important tool for the study of the working alliance in telepsychotherapy.

The effect of user interface on treatment engagement in a self-guided digital problem-solving intervention: A randomized controlled trial

BACKGROUND

Resources are spent worldwide on the development of digital platforms and their user interfaces (UIs) for digital mental health services (DMHS). However, studies investigating the potential benefits of different UIs for DMHS are currently lacking. To fill this knowledge gap, the aim of this study was to investigate differences in treatment engagement between two different UIs for DMHS.

METHODS

A total of 397 participants from the Swedish general public were randomized (1:1) to use a self-guided digital problem-solving intervention during one week, either with an optimized UI (N = 198), based on user experience (UX) design principles and with automated features, or a basic UI (N = 199), analogous with a UI used in Swedish regular health care comprising elementary UI features and less automation. Primary outcome measures were self-rated usability, on the System Usability Scale, and treatment credibility, on the Credibility/Expectancy Questionnaire. Secondary outcome measures included behavioral engagement with the intervention.

FINDINGS

There were no significant differences between the UIs in ratings of usability or treatment credibility. However, participants who used the optimized UI were significantly more engaged with the intervention as measured by usage of the intervention at least once (odds ratio 2.54, 95% CI [1.67, 3.85]), total number of generated solutions (mean difference 1.41, 95% CI [0.72, 2.11]), and mean number of generated solutions per initiated problem-solving attempt (mean difference 1.45, 95% CI [1.06, 1.85]). Other findings included participants using the optimized UI rating the intervention as easier to understand, while feeling more overwhelmed, than those using the basic UI.

INTERPRETATION

Our findings indicate that an optimized UI based on UX design principles, in comparison to a basic UI comprising elementary UI features, do not affect overall self-rated usability or treatment credibility but increases some measures of behavioral engagement with a digital intervention.

FUNDING

Funded by the Government of Sweden, Ministry of Health and Social Affairs.

Effects of a tailored multidisciplinary counselling intervention to support the adjustment process after a traumatic injury: a randomized controlled trial

PURPOSE

To investigate the efficacy of a tailored counselling intervention for injured workers regarding different aspects of subjective well-being.

MATERIALS AND METHODS

Prospective randomized controlled trial with 192 mildly-to-moderately injured workers who were on sick leave for at least 18 weeks and showed a high-risk profile for a complicated rehabilitation process in a screening. Patients were assessed at baseline, 12 and 18 months post-injury. The outcome variables concerned five aspects of subjective well-being (negative feelings, life and job satisfaction, satisfaction related to family and health). Both the control and the experimental group received conventional case management. Participants in the intervention group additionally received tailored workplace interventions and/or mental health counselling sessions.

RESULTS

Participants in the intervention group received an average of 2.23 (SD = 6.94) counselling sessions. Both groups showed a significant reduction (mean (95% CI) of negative feelings control group 2.6 (2.3-3.4), intervention group 2.4 (1.6-3.4)), with a significant difference in negative feelings between the groups (p = 0.01).

CONCLUSIONS

Our results suggest that a tailored counselling intervention has a modest long-term effect (d = 0.74) on negative feelings for mildly-to-moderately injured workers. However, future studies should evaluate the feasibility of this study's treatment approach.Implications for rehabilitationAccidents and the resulting injuries often cause a wide range of burdens including psychosocial and emotional distress as well as long-time sick leaves.Tailored counselling led to significant reductions of negative feelings in mildly-to-moderately injured workers over time.By showing that even conventional case management can have a beneficial effect on subjective wellbeing, the results of this study reaffirm the holistic biopsychosocial nature of injury rehabilitation.

Internet-delivered cognitive processing therapy for individuals with a history of bullying victimization: a randomized controlled trial

The purpose of this randomized controlled trial was to test an internet-delivered version of cognitive processing therapy (CPT) for the psychological distress associated with bullying victimization. The sample comprised 52 adults (i.e. 69.20% women; mean age = 43.37 (SD = 12.47); 3.85% ethnic minority) who self-identified as having a lifetime history of bullying victimization. Participants were randomized into three groups, which received 12 sessions of internet-delivered, therapist-guided, and content-modified version of CPT, 12 sessions of internet-delivered and therapist-guided stress management (SM), or a waitlist. Treatment outcomes included maladaptive trauma appraisals, symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety and stress, social anxiety, and anger. Hierarchical linear modeling was used to analyse the data. Findings indicated that CPT was effective in reducing the strength of maladaptive appraisals related to bullying victimization and symptoms of PTSD compared to the waitlist and SM. SM outperformed CPT and the waitlist in reducing symptoms of depression, general anxiety, and stress. In conclusion, the results of this trial suggest that internet-delivered CPT is effective for the psychological distress and maladaptive appraisals associated with bullying victimization but that adaptions might be needed to target more effectively symptoms of anxiety and depression.

Contextual assessment: evaluating a novel self-guided online therapeutic assessment

BACKGROUND

Paper introduces Conflict Analysis (CA), an online self-guided therapeutic assessment. CA combines a diagnostic self-report scale with narrative exercises and self-analytical tasks. CA automatically generates detailed diagnostic records and frameworks for changes.

OBJECTIVE

To evaluate therapeutic and diagnostic benefits associated with CA over time.

METHODS

This online study compared CA over 2 weeks on outcome measures predicting psychotherapy outcome. Novel scale measuring perceived diagnostic benefit and perceived therapeutic benefit was delivered at post and follow-up. Cohort (n = 59, average age = 35, 50% female) was either in therapy or interested to start therapy in near future.

RESULTS

Repeated-measure ANOVAs suggest that scores significantly changed on measures predicting negative affect, depression, performance and appearance self-esteem, insight, and growth initiative. Agreement rates on items measuring perceived diagnostic and therapeutic benefits were at least 74.5% for both post and follow-up.

CONCLUSIONS

Evidence supports further exploration of CA as a self-guided diagnostic and therapeutic resource.Key pointsResults demonstrate feasibility and utility of online self-guided therapeutic assessment.Described model is associated with increased perceived diagnostic and therapeutic benefits.Described model illustrates therapeutic benefits over time.Results demonstrate that even self-guided assessment can have therapeutic implications.

Commencement of and Retention in Web-Based Interventions and Response to Prompts and Reminders: Longitudinal Observational Study Based on Two Randomized Controlled Trials

BACKGROUND

Web-based interventions are effective for several psychological problems. However, recruitment, adherence, and missing data are challenges when evaluating these interventions.

OBJECTIVE

This study aimed to describe the use patterns during the commencement phase, possible retention patterns (continuation of data provision), and responses to prompts and reminders among participants in 2 randomized controlled trials (RCTs) evaluating web-based interventions.

METHODS

Data on use patterns logged in 2 RCTs aiming to reduce symptoms of anxiety and depression among adult patients recently diagnosed with cancer (AdultCan RCT) and patients with a recent myocardial infarction (Heart RCT) were analyzed. The web-based intervention in the AdultCan trial consisted of unguided self-help and psychoeducation and that in the Heart trial consisted of therapist-supported cognitive behavioral therapy. In total, 2360 participants' use patterns at first log-in, including data collection at baseline (ie, commencement) and at 2 follow-ups, were analyzed. Both the intervention and comparison groups were analyzed.

RESULTS

At commencement, 70.85% (909/1283) and 86.82% (935/1077) of the participants in AdultCan and Heart RCTs, respectively, logged in and completed baseline data collection after receiving a welcome email with log-in credentials. The median duration of the first log-in was 44 minutes and 38 minutes in AdultCan and Heart RCTs, respectively. Slightly less than half of the participants' first log-ins were completed outside standard office hours. More than 80% (92/114 and 103/111) of the participants in both trials explored the intervention within 2 weeks of being randomized to the treatment group, with a median duration of 7 minutes and 47 minutes in AdultCan and Heart RCTs, respectively. There was a significant association between intervention exploration time during the first 2 weeks and retention in the Heart trial but not in the AdultCan trial. However, the control group was most likely to retain and provide complete follow-up data. Across the 3 time points of data collection explored in this study, the proportion of participants responding to all questionnaires within 1 week from the prompt, without a reminder, varied between 35.45% (413/1165) and 66.3% (112/169). After 2 reminders, up to 97.6% (165/169) of the participants responded.

CONCLUSIONS

Most participants in both RCTs completed the baseline questionnaires within 1 week of receiving the welcome email. Approximately half of them answered questions at baseline data collection outside office hours, suggesting that the time flexibility inherent in web-based interventions contributes to commencement and use. In contrast to what was expected, the intervention groups generally had lower completion rates than the comparison groups. About half of the participants completed the questionnaires without a reminder, but thereafter, reminders contributed to both baseline and follow-up retention, suggesting they were effective. Strategies to increase commencement of and retention in eHealth interventions are important for the future development of effective interventions and relevant research.

Acceptability of tDCS in treating stress-related mental health disorders: a mixed methods study among military patients and caregivers

BACKGROUND

Noninvasive brain stimulation techniques like transcranial direct current stimulation (tDCS) offer potential new approaches to treat stress-related mental health disorders. While the acceptability of tDCS as a treatment tool plays a crucial role in its development and implementation, little is known about tDCS acceptability for users in mental healthcare, especially in the context of stress-related disorders.

METHODS

Using a mixed-methods approach, we investigated tDCS acceptability among 102 active duty and post-active military patients with stress-related symptoms (posttraumatic stress disorder, anxiety and impulsive aggression) who participated in a 5-session tDCS intervention. Quantitative dropout and adverse effects data was collected for all patients involved in the sham-controlled tDCS intervention. We additionally explored perspectives on the acceptability of tDCS treatment via a theory-based semi-structured interview. A subgroup of patients as well as their caregivers were interviewed to include the views of both patients and mental healthcare professionals.

RESULTS

Quantitative outcomes showed minimal tDCS-related adverse effects (mild itching or burning sensations on the scalp) and high tDCS treatment adherence (dropout rate: 4% for active tDCS, 0% for sham). The qualitative outcomes showed predominantly positive attitudes towards tDCS interventions for stress-related disorders, but only as complementary to psychotherapy. Remarkably, despite the perception that sufficient explanation was provided, patients and caregivers stressed that tDCS treatment comprehension was limited and should improve. Also, the travel associated with frequent on-site tDCS sessions may produce a significant barrier to care for patients with stress-related disorders and active-duty military personnel.

CONCLUSIONS

Acceptability numbers and perspectives from military patients and caregivers suggest that tDCS is an acceptable complementary tool in the treatment of stress-related disorders. Critically, however, if tDCS is to be used beyond scientific studies, adequately educating users on tDCS working mechanisms is vital to further improve its acceptability. Also, the perceived potential barrier to care due to frequent travel may favor home-based tDCS solutions.

TRIAL REGISTRATION

The tDCS intervention was part of a sham-controlled trial registered on 05-18-2016 at the Netherlands Trial Register with ID NL5709 .

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

BACKGROUND

Missing cases present a challenge to our ability to evaluate the effects of web-based psychotherapy trials. As missing cases are often lost to follow-up, less is known about their characteristics, their likely clinical outcomes, or the likely effect of the treatment being trialed.

OBJECTIVE

The aim of this study is to explore the characteristics of missing cases, their likely treatment outcomes, and the ability of different statistical models to approximate missing posttreatment data.

METHODS

A sample of internet-delivered cognitive behavioral therapy participants in routine care (n=6701, with 36.26% missing cases at posttreatment) was used to identify predictors of dropping out of treatment and predictors that moderated clinical outcomes, such as symptoms of psychological distress, anxiety, and depression. These variables were then incorporated into a range of statistical models that approximated replacement outcomes for missing cases, and the results were compared using sensitivity and cross-validation analyses.

RESULTS

Treatment adherence, as measured by the rate of progress of an individual through the treatment modules, and higher pretreatment symptom scores were identified as the dominant predictors of missing cases probability (Nagelkerke R²=60.8%) and the rate of symptom change. Low treatment adherence, in particular, was associated with increased odds of presenting as missing cases during posttreatment assessment (eg, odds ratio 161.1:1) and, at the same time, attenuated the rate of symptom change across anxiety (up to 28% of the total symptom with 48% reduction effect), depression (up to 41% of the total with 48% symptom reduction effect), and psychological distress symptom outcomes (up to 52% of the total with 37% symptom reduction effect) at the end of the 8-week window. Reflecting this pattern of results, statistical replacement methods that overlooked the features of treatment adherence and baseline severity underestimated missing case symptom outcomes by as much as 39% at posttreatment.

CONCLUSIONS

The treatment outcomes of the cases that were missing at posttreatment were distinct from those of the remaining observed sample. Thus, overlooking the features of missing cases is likely to result in an inaccurate estimate of the effect of treatment.

The Influence of Three Modes of Human Support on Attrition and Adherence to a Web- and Mobile App-Based Mental Health Promotion Intervention in a Nonclinical Cohort: Randomized Comparative Study

Background

The escalating prevalence of mental health disorders necessitates a greater focus on web- and mobile app–based mental health promotion initiatives for nonclinical groups. However, knowledge is scant regarding the influence of human support on attrition and adherence and participant preferences for support in nonclinical settings.

Objective

This study aimed to compare the influence of 3 modes of human support on attrition and adherence to a digital mental health intervention for a nonclinical cohort. It evaluated user preferences for support and assessed whether adherence and outcomes were enhanced when participants received their preferred support mode.

Methods

Subjects participated in a 10-week digital mental health promotion intervention and were randomized into 3 comparative groups: standard group with automated emails (S), standard plus personalized SMS (S+pSMS), and standard plus weekly videoconferencing support (S+VCS). Adherence was measured by the number of video lessons viewed, points achieved for weekly experiential challenge activities, and the total number of weeks that participants recorded a score for challenges. In the postquestionnaire, participants ranked their preferred human support mode from 1 to 4 (S, S+pSMS, S+VCS, S+pSMS & VCS combined). Stratified analysis was conducted for those who received their first preference. Preintervention and postintervention questionnaires assessed well-being measures (ie, mental health, vitality, depression, anxiety, stress, life satisfaction, and flourishing).

Results

Interested individuals (N=605) enrolled on a website and were randomized into 3 groups (S, n=201; S+pSMS, n=202; S+VCS, n=201). Prior to completing the prequestionnaire, a total of 24.3% (147/605) dropped out. Dropout attrition between groups was significantly different (P=.009): 21.9% (44/201) withdrew from the S group, 19.3% (39/202) from the S+pSMS group, and 31.6% (64/202) from the S+VCS group. The remaining 75.7% (458/605) registered and completed the prequestionnaire (S, n=157; S+pSMS, n=163; S+VCS, n=138). Of the registered participants, 30.1% (138/458) failed to complete the postquestionnaire (S, n=54; S+pSMS, n=49; S+VCS, n=35), but there were no between-group differences (P=.24). For the 69.9% (320/458; S, n=103; S+pSMS, n=114; S+VCS, n=103) who completed the postquestionnaire, no between-group differences in adherence were observed for mean number of videos watched (P=.42); mean challenge scores recorded (P=.71); or the number of weeks that challenge scores were logged (P=.66). A total of 56 participants (17.5%, 56/320) received their first preference in human support (S, n=22; S+pSMS, n=26; S+VCS, n=8). No differences were observed between those who received their first preference and those who did not with regard to video adherence (P=.91); challenge score adherence (P=.27); or any of the well-being measures including, mental health (P=.86), vitality (P=.98), depression (P=.09), anxiety (P=.64), stress (P=.55), life satisfaction (P=.50), and flourishing (P=.47).

Conclusions

Early dropout attrition may have been influenced by dissatisfaction with the allocated support mode. Human support mode did not impact adherence to the intervention, and receiving the preferred support style did not result in greater adherence or better outcomes.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR): 12619001009101; http://www.anzctr.org.au/ACTRN12619001009101.aspx

Childbirth experiences among women with fear of birth randomized to internet-based cognitive therapy or midwife counseling

Background: Although women with fear of birth often report negative birth experiences, few studies have focused on their experiences in the long term. The aim of this study was to compare birth experiences a year after childbirth in two groups of women receiving treatment for experiencing fear of birth during pregnancy.Methods: As part of the U-CARE: Pregnancy Trial, a prospective multicenter randomized controlled trial comparing the effects of internet-based cognitive behavioral therapy (iCBT) and standard care among pregnant women with fear of birth. Women were recruited at three Swedish hospitals following a screening procedure that assessed their fear of birth. Data were collected online with the Childbirth Experience Questionnaire (CEQ), one question about the overall birth experience, and questions about personal background, collected before randomization.Results: A total of 181 women responded to the follow-up questionnaire a year after childbirth. Approximately half of participants reported a less positive birth experience. Preferred mode of birth, actual mode of birth, marital status and psychiatric history were associated with the domains of the CEQ. However, no statistically significant differences emerged between the treatment groups.Conclusions: Being randomized to receive iCBT or counseling with midwives for fear of birth was not associated with perceptions of the birth experience assessed a year after birth. Most participants reported less-than-positive birth experiences and scored low on the domain of the CEQ reflecting Own capacity. In response, additional research remains necessary to identify the best model of care that might facilitate positive experiences with giving birth among women with fear of birth.

Promises and risks of web-based interventions in the treatment of depression

Major depression (MD) is a highly prevalent and severe disorder with many patients having no access to efficient treatments such as pharmaco- and psychotherapy. Web-based interventions promise to be a method to provide resource-efficient and widespread access to psychotherapeutic support. Meta-analyses summarizing studies that use face-to-face psychotherapy as a comparator provide evidence for equivalent antidepressant efficacy. Web-based interventions seem to be particularly efficacious when they are accompanied by some form of professional guidance. However, they are also associated with a variety of possible risks (eg, suicidal crises can be overlooked) and unwanted effects (eg, increase in rumination and somatization due to self-monitoring) that are so far under-studied. Although some naturalistic studies yield smaller effect sizes than randomized controlled trials (RCTs), well-designed interventions with adequate guidance have been shown to be successfully integrable into routine care.


Outpatient and self-referred participants: Adherence to treatment components and outcome in an internet intervention targeting anxiety disorders

OBJECTIVE

While adherence is an important factor influencing the effectiveness of internet interventions, many studies operationalize adherence only by the number of sessions and do not report adherence to specific treatment components. The goal of this study was to investigate adherence to treatment components as well as outcome in outpatients and self-referred participants who participated in an internet intervention targeting anxiety.

METHOD

Outpatients (N = 50) were compared to self-referred (N = 37) participants and a matched outpatient waitlist sample (based on nearest neighbor matching): Using t-test and χ2 tests adherence to treatment components based on the number of completed exercises was compared between participant groups. A 2 × 2 repeated measures ANOVA was used to compare pre-to post symptom change between participant groups. Primary measures included the Generalized Anxiety Disorder Scale-7 (GAD-7) and the Mini Social Phobia Inventory (Mini-SPIN). Using nonparametric bootstrap analyses number of sessions and adherence to treatment components were investigated as potential mediators of the relationship between participant group and outcome. Finally, predictors of adherence to treatment components in outpatient participants were investigated using LASSO and logistic regression.

RESULTS

Self-referred participants were more adherent than outpatient participants, however the groups did not differ significantly in outcome. Outpatient participants who adhered to relaxation showed greater improvement during the waiting period than the matched outpatient waitlist sample. The effect of participant group on outcome was mediated via adherence to exposure and number of sessions.

CONCLUSIONS

In internet interventions adherence to treatment components differs between participant groups and has a mediating effect on treatment outcome. Therefore, it should be fostered, especially when participants are not self-referred. In line with these findings more studies should investigate relevant participant characteristics in more depth.

The effects of retrieval versus rehearsal of online problem-solving therapy sessions on recall, problem-solving skills and distress in distressed individuals: An experimental study

BACKGROUND AND OBJECTIVES

Improving memory for the content of therapy sessions might increase the effects of psychological interventions. Previous studies showed that healthy individuals who took a memory test (retrieval) of studied material showed better long-term memory retention than individuals who restudied (rehearsal) the material. The aim of the current study was to find out whether we can translate these findings to a subclinical setting.

METHODS

Individuals with moderate levels of distress were randomized into retrieving (n = 46) or rehearsing (n = 49) four weekly sessions of online Problem-Solving Therapy (PST). Session recall, problem-solving skills and distress were measured at baseline, three days after each session and at one-week follow-up.

RESULTS

Retrieval led to overall higher recall, but this difference disappeared when controlling for the time spent on retrieval versus rehearsal. Retrieval did not lead to better problem-solving skills or less distress, compared to rehearsal. Baseline working memory performance moderated the effect of condition on recall after controlling for the time spent on retrieval versus rehearsal: the effect of retrieval compared to rehearsal on recall was larger for individuals with lower working memory performance.

LIMITATIONS

The sample mostly consisted of university students with overall high working memory scores.

CONCLUSIONS

This study provided the first evidence that retrieval of the content of PST sessions may lead to better session recall compared to rehearsal of the PST sessions in individuals with a low working memory score. Implications for the use of cognitive support strategies within a therapeutic setting are discussed.

Clinical and cost-effectiveness of guided internet-based interventions in the indicated prevention of depression in green professions (PROD-A): study protocol of a 36-month follow-up pragmatic randomized controlled trial

BACKGROUND

People in green professions are exposed to a variety of risk factors, which could possibly enhance the development of depression. Amongst possible prevention approaches, internet- and mobile-based interventions (IMIs) have been shown to be effective and scalable. However, little is known about the effectiveness in green professions. The aim of the present study is to examine the (cost-)effectiveness of a tailored IMI program for reducing depressive symptoms and preventing the onset of clinical depression compared to enhanced treatment as usual (TAU+).

METHODS

A pragmatic randomized controlled trial (RCT) will be conducted to evaluate a tailored and therapeutically guided preventive IMI program in comparison to TAU+ with follow-ups at post-treatment (9 weeks), 6-, 12-, 24-, and 36-months. Entrepreneurs in green professions, collaborating spouses, family members and pensioners (N = 360) with sufficient insurance status and at least subthreshold depression (PHQ-9 ≥ 5) are eligible for inclusion. Primary outcome is depressive symptom severity (QIDS-SR16). Secondary outcomes include incidence of depression (QIDS-SR16), quality of life (AQoL-8D) and negative treatment effects (INEP). A health-economic evaluation will be conducted from a societal perspective. The IMI program is provided by psychologists of an external service company and consists of six guided IMIs (6-8 modules, duration: 6-8 weeks) targeting different symptoms (depressive mood, depressive mood with comorbid diabetes, perceived stress, insomnia, panic and agoraphobic symptoms or harmful alcohol use). Intervention choice depends on a screening of participants' symptoms and individual preferences. The intervention phase is followed by a 12-months consolidating phase with monthly contact to the e-coach.

DISCUSSION

This is the first pragmatic RCT investigating long-term effectiveness of a tailored guided IMI program for depression prevention in green professions. The present trial builds on a large-scale strategy for depression prevention in green professions. The intended implementation of the IMI program with a nationwide rollout has the potential to reduce overall depression burden and associated health care costs in case of given effectiveness.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00014000 . Registered on 09 April 2018.

Predicting engagement with an online psychosocial intervention for psychosis: Exploring individual- and intervention-level predictors

BACKGROUND

Individuals with psychosis demonstrate positive attitudes towards utilising digital technology in mental health treatment. Although preliminary research suggests digital interventions are feasible and acceptable in this population, little is known about how to best promote engagement with these resources. Candidate predictors include therapist support, sources of motivation and recovery style. Understanding what factors predict engagement will aid more effective design and implementation of digital interventions to improve clinical benefits.

OBJECTIVE

This study aimed to investigate demographic, psychological, and treatment variables that predict overall and type of engagement with a psychosocial, online intervention for individuals with psychosis.

METHODS

Ninety-eight participants with a history of psychosis were given access to a web program containing modules on self-management and recovery, which they were asked to use flexibly at their own pace. Activity was automatically logged by the system. Baseline measures of demographics, recovery style and motivation were administered, and participants were randomised to receive either website access alone, or website access plus weekly, asynchronous emails from an online coach over 12 weeks. Log and baseline assessment data were used in negative binomial regressions to examine predictors of depth and breadth of use over the intervention period. A logistic regression was used to examine the impact of predictor variables on usage profiles (active or passive).

RESULTS

Depth and breadth of engagement were positively predicted by receiving email support, low levels of externally controlled motivations for website use, older age, and having a tertiary education. There was a significant interaction between level of controlled motivation and condition (+/-email) on breadth and depth of engagement: receiving asynchronous emails was associated with increased engagement for individuals with low, but not high, levels of externally controlled motivations. Receiving email support and more autonomous motivations for treatment predicted more active use of the website.

CONCLUSIONS

Asynchronous email support can promote engagement with online interventions for individuals with psychosis, potentially enabling self-management of illness and improving clinical outcomes. However, those using online interventions due to external motivating factors, may have low levels of engagement with the intervention, irrespective of coaching provided. These findings may guide design and implementation of future online interventions in this population.

Dutch Translation and Adaptation of the Treatment Beliefs Questionnaire for Chronic Pain Rehabilitation

Background

The Treatment Beliefs Questionnaire has been developed to measure patients' beliefs of necessity of and concerns about rehabilitation. Preliminary evidence suggests that these beliefs may be associated with attendance of rehabilitation. The aim of this study was to translate and adapt the Treatment Beliefs Questionnaire for interdisciplinary pain rehabilitation and to examine the measurement properties of the Dutch translation including the predictive validity for dropout.

Methods

The questionnaire was translated in 4 steps: forward translation from English into Dutch, achieving consensus, back translation into English, and pretesting on providers and patients. In order to establish structural validity, internal consistency, construct validity, and predictive validity of the questionnaire, 188 participants referred to a rehabilitation centre for outpatient interdisciplinary pain rehabilitation completed the questionnaire at the baseline. Dropout was measured as the number of patients starting, but not completing the programme. For reproducibility, 51 participants were recruited at another rehabilitation centre to complete the questionnaire at the baseline and one week later.

Results

We confirmed the structural validity of the Treatment beliefs Questionnaire in the Dutch translation with three subscales, necessity, concerns, and perceived barriers. internal consistency was acceptable with ordinal alphas ranging from 0.66–0.87. Reproducibility was acceptable with ICC_{2,1 agreement} ranging from 0.67–0.81. Hypotheses testing confirmed construct validity, similar to the original questionnaire. Predictive validity showed the questionnaire was unable to predict dropouts.

Conclusion

Cross-cultural translation was successfully completed, and the Dutch Treatment Beliefs Questionnaire demonstrates similar psychometric properties as the original English version.

Attrition in an Online Loneliness Intervention for Adults Aged 50 Years and Older: Survival Analysis

BACKGROUND

Online interventions can be as effective as in-person interventions. However, attrition in online intervention is high and potentially biases the results. More importantly, high attrition rates might reduce the effectiveness of online interventions. Therefore, it is important to discover the extent to which factors affect adherence to online interventions. The setting for this study is the online Friendship Enrichment Program, a loneliness intervention for adults aged 50 years and older.

OBJECTIVE

This study examined the contribution of severity of loneliness, coping preference, activating content, and engagement in attrition within an online intervention.

METHODS

Data were collected from 352 participants in an online loneliness intervention for Dutch people aged 50 years and older. Attrition was defined as not completing all 10 intervention lessons. The number of completed lessons was assessed through the management system of the intervention. We tested 4 hypotheses on attrition by applying survival analysis (Cox regression).

RESULTS

Of the 352 participants who subscribed to the intervention, 46 never started the introduction. The remaining 306 participants were divided into 2 categories: 73 participants who did not start the lessons of the intervention and 233 who started the lessons of the intervention. Results of the survival analysis (n=233) showed that active coping preference (hazard ratio [HR]=0.73), activating content (HR=0.71), and 2 indicators of engagement (HR=0.94 and HR=0.79) lowered attrition. Severity of loneliness was not related to attrition.

CONCLUSIONS

To reduce attrition, developers of online (loneliness) interventions may focus on stimulating active behavior within the intervention.