How do eHealth Programs for Adolescents With Depression Work? A Realist Review of Persuasive System Design Components in Internet-Based Psychological Therapies

Mining User Reviews for Key Design Features in Cognitive Behavioral Therapy-Based Mobile Mental Health Apps

Background: Cognitive behavioral therapy (CBT)-based mobile apps have been shown to improve CBT-based interventions effectiveness. Despite the proliferation of these apps, user-centered guidelines pertaining to their design remain limited. The study aims to identify design features of CBT-based apps using online app reviews. Methods: We used 4- and 5-star reviews, preprocessed the reviews, and represented the reviews using word-level bigrams. Then, we leveraged latent Dirichlet allocation (LDA) and visualization techniques using python library for interactive topic model visualization to analyze the review and identify design features that contribute to the success and effectiveness of the app. Results: A total of 24,902 reviews were analyzed. LDA optimization resulted in 86 topics that were labeled by two independent researchers, with an interrater Cohen's kappa value of 0.86. The labeling and grouping process resulted in a total of six main design features for effective CBT-based mobile apps, namely, mental health management and support, credibility support, self-understanding and personality insights, therapeutic approaches and tools, beneficial rescue sessions, and personal growth and development. Conclusions: The high-level design features identified in this study could evidently serve as the backbone of successful CBT-based mobile apps for mental health.

Effectiveness of technology-assisted vs face-to-face cognitive behavioural therapy for anxiety and depression in children and young people: A systematic review and meta-analysis

BACKGROUND

Cognitive Behavioural Therapy (CBT) has been proven to be effective for anxiety and depression in children and young people (CYP). Over the past 20 years there have been several attempts at delivering CBT through apps, online software, videogames, but also with a therapist via phone or videoconferencing platforms, with promising results for the "technology-assisted" versions. However, most research, have compared online CBT to waiting lists, and not many studies looked at the effectiveness of face-to-face (f2f) CBT versus technology-assisted CBT.

METHODS

Adopting the PRISMA guidelines, we evaluated 1849 citations and identified 10 eligible studies. Studies were identified through the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PubMed/MEDLINE, Web of Science, and Scopus.

RESULTS

Ten studies met our inclusion criteria. The studies included a variety of technology-assisted forms of CBT, including videoconferencing and online CBT. Of these, seven looked at the effectiveness of technology-assisted CBT for anxiety in CYP, and seven looked at depression. The meta-analyses had low heterogeneity and showed that technology-assisted CBT was non-inferior to f2f CBT for anxiety and depression in CYP (d = 0.06 and 0.12 respectively).

CONCLUSIONS

Technology-assisted CBT may be a valid alternative for the treatment of anxiety and depression in CYP. Future studies should consider what specific delivery modalities are most cost-effective.

How online pro-environmental games affect users' pro-environmental behavioural intentions? - Insights from Ant Forest

Information technology has created new ways for people to participate in environmental protection. Ant Forest, a pro-environmental game that actively encourages users to take part in offline environmental activities through online gaming content, has gained great popularity. However, research in this area is still limited, and the effect of playing such games on users' pro-environmental intentions in real life and the underlying mechanisms are unknown. Therefore, this research draws from Persuasive Systems Design model and value theory and examines the relationships between design features of Ant Forest, users' values and their pro-environmental behavioural intentions. The research model is empirically tested by survey data from 428 Ant Forest users. Results indicate that users' self-enhancement values, including utilitarian, hedonic and social values, and self-transcendence values, including altruistic and biospheric values, all positively affect their continued gameplay intentions and therefore affect their pro-environmental behavioural intentions. Additionally, the primary task support, social support, dialogue support, and system credibility of Ant Forest have varying positive effects on users' perceived values.

Preferences for Text Messaging Supports During Youth Transition to Adult Mental Health Services: Theory-Informed Modified e-Delphi Study

BACKGROUND

For many young people, the transition from child to adult mental health services is a vulnerable time associated with treatment disengagement and illness progression. Providing service information and options to youth, appealing to them, and tailoring to their needs during this period could help overcome systematic barriers to a successful transition. We know little about how SMS text message-based interventions might be leveraged to support the motivational, informational, and behavioral needs of youth during this time. Ascertaining youth preferences for the content and functionality of an SMS text message service could inform prototype development.

OBJECTIVE

This study investigated consensus preferences among youth on important content, technology features, and engagement supports to inform a transition-focused SMS text message service.

METHODS

A modified e-Delphi survey design was used to collect demographics, current levels of technology use, importance ratings on message content, preferred technical features, and barriers and enablers to engagement for youth in Canada aged 16-26 years who have accessed mental health services within the past 5 years. Survey items on content were categorized according to the information-motivation-behavioral skills (IMB) model. Survey items on technical features were categorized according to the persuasive system design (PSD) model. A predefined consensus rating matrix and descriptive statistics were used to characterize the sample. The high consensus threshold was 70%.

RESULTS

A total of 100 participants, predominantly non-White (n=47, 47%), aged 20-26 years (n=59, 59%), and who had first accessed mental health services between the ages of 13 and 19 years (n=60, 60%), were selected. The majority (n=90, 90%) identified as daily SMS text message users. A high level of consensus on importance ratings was reported in 45% (9/20) of content items based on the IMB model. There were higher levels of consensus on importance ratings related to behavior domain items (3/3, 100%) than information domain items (4/9, 44%) or motivation domain items (2/8, 25%). A high level of consensus on importance ratings was reported in only 19% (4/21) of feature and functionality items based on the PSD model. Among PSD model categories, there was a high level of consensus on importance ratings in 8% (1/12) of the primary task support domain items and 100% (3/3) of the system credibility support domain items. None of the dialogue-support and social-support domain items met the high level of consensus thresholds. In total, 27% (27/100) of youth indicated that the most significant enabler for engaging with a transition-focused SMS text message intervention was the personalization of text messages.

CONCLUSIONS

Scientists developing next-generation SMS text messaging interventions for this population need to consider how levels of consensus on different features may impact feasibility and personalization efforts. Youth can (and should) play an integral role in the development of these interventions.

Effectiveness of internet-delivered psychological treatments for children and adolescents with anxiety and/or depressive disorders: Systematic review and network meta-analysis

Background

Anxiety and depression symptomatology has increased in the child and adolescent population. Internet-delivered psychological treatments (IDPT) can help to reduce this symptomatology, attending to the largest possible population.

Aim

To conduct a systematic review and network meta-analysis of IDPT to reduce anxiety and depression symptoms in children and adolescents.

Methods

The search for studies was conducted in SCOPUS, PsycINFO, PSICODOC, PsycARTICLES and Medline, between 2000 and 2022, in December 2022. Studies were selected if they were conducted with a sample of children and/or adolescents with previous symptoms of anxiety and depression, had applied IDPT, and included at least two comparative groups with pretest-posttest measures. Network meta-analyses were separately performed for anxiety and depression outcomes. Publication bias was analyzed using Egger's test and funnel plots, and mixed-effects meta-regression models were applied to account for heterogeneity.

Results

37 studies were included in the meta-analysis, providing a total of 74 comparative groups. IDPT exhibited low-to-moderate, statistically significant average effect sizes when compared to both inactive and active controls. No statistical significance was found when IDPT was compared with other types of interventions.

Discussion

IDPT is recommended to reduce anxiety and depression symptomatology in children and adolescents, but more studies are needed which compare treatments with other types of interventions, such as face-to-face therapy.

Telepsychiatry in the Treatment of Major Depressive Disorders

This chapter explores the transformative role of telepsychiatry in managing major depressive disorders (MDD). Traversing geographical barriers and reducing stigma, this innovative branch of telemedicine leverages digital platforms to deliver effective psychiatric care. We investigate the evolution of telepsychiatry, examining its diverse interventions such as videoconferencing-based psychotherapy, medication management, and mobile applications. While offering significant advantages like increased accessibility, cost-effectiveness, and improved patient engagement, challenges in telepsychiatry include technological barriers, privacy concerns, ethical and legal considerations, and digital literacy gaps. Looking forward, emerging technologies like virtual reality, artificial intelligence, and precision medicine hold immense potential to personalize and enhance treatment effectiveness. Recognizing its limitations and advocating for equitable access, this chapter underscores telepsychiatry's power to revolutionize MDD treatment, making quality mental healthcare a reality for all.

StudiCare procrastination - Randomized controlled non-inferiority trial of a persuasive design-optimized internet- and mobile-based intervention with digital coach targeting procrastination in college students

BACKGROUND

Academic procrastination is widespread among college students. Procrastination is strongly negatively correlated with psychological well-being, thus early interventions are needed. Internet- and mobile-based cognitive behavioral therapy (iCBT) could provide a low-threshold treatment option. Human guidance seems to be a decisive mechanism of change in iCBT. Persuasive design optimization of iCBT and guidance by a digital coach might represent a resource-saving alternative. The study evaluated the non-inferiority of a digital coach in comparison to human guidance with regard to the primary outcome procrastination.

METHODS

The iCBT StudiCare procrastination was optimized by principles of the Persuasive System Design (PSD). A total of 233 college students were randomly assigned to either StudiCare procrastination guided by a digital coach (intervention group, IG) or by a human eCoach (control group, CG). All participants were assessed at baseline, 4-, 8- and 12-weeks post-randomization. Symptom change and between-group differences were assessed with latent growth curve models and supported by effect size levels. The non-inferiority margin was set at Cohen's d = - 0.3.

RESULTS

The primary outcome procrastination measured by the Irrational Procrastination scale (IPS) significantly decreased across groups (γ = - 0.79, p < .001, Cohen's d = -0.43 to -0.89) from baseline to 12-weeks post-randomization. There were no significant differences between groups (γ = -0.03, p = .84, Cohen's d = -0.03 to 0.08). Regarding symptoms of depression, no significant time x group effect was found (γ = 0.26, p = .09; Cohen's d = -0.15 to 0.21). There was also no significant time x group effect on the improvement of symptoms of anxiety (γ = 0.25, p = .09). However, Cohen's ds were above the non-inferiority margin 8-weeks (Cohen's d = 0.51) and 12-weeks post-randomization (Cohen's d = 0.37), preferring the CG. Of the IG, 34% and of the CG, 36% completed 80% of the modules.

CONCLUSIONS

The PSD optimized version of StudiCare procrastination is effective in reducing procrastination. The digital coach was not inferior to human guidance. Guidance by a digital coach in iCBT against procrastination for college students could be a resource-saving alternative to human guidance.

TRIAL REGISTRATION

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trial Register (ID: DRKS00025209, 30/04/2021).

Systematic Review and Meta-analysis: International Prevalence of Suicidal Ideation and Attempt in Youth

OBJECTIVE

Globally, rates of youth suicide vary considerably. Suicidal thoughts and behaviors (STB) are consistently associated with risk of death by suicide. However, international trends in STB have not yet been compared. To address this gap, an international meta-analysis of epidemiological and school-based studies that report on STB in youth was conducted.

METHOD

Systematic searches were conducted in PubMed and PsycINFO through April 2022. Eligible studies included prevalence of active suicidal ideation (SI) or suicide attempts (SA) in community youth younger than age 22. All studies were coded by 2 authors. Mixed models accounting for shared methods and including hypothesized moderators were conducted using the metafor package in R.

RESULTS

There were 371 effect sizes for SI, 94 for SI with a plan, and 316 for SA, representing 149 regions. Year of data collection ranged from 1981 to 2021. Participants were 6 to 21 years old. The prevalence of SI ranged across regions from 14.3% to 22.6%; the prevalence of SA ranged from 4.6% to 15.8%. Year was not associated with increasing STB prevalence except for studies from the United States, which showed increasing rates of SI and SA since 2007.

CONCLUSION

This is the most comprehensive meta-analysis of STB in youth, providing valuable data about how risk factors most commonly associated with suicide vary internationally and over time. International rates of STB among youth are not improving and may be getting worse in the United States, despite efforts to reduce suicide risk. Most studies did not report rates of SI or SA separately for LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others) youth and youth of color. A better understanding of proximal risk at the individual level will be important to informing future prevention efforts, especially for high-risk groups.

In which context and for whom can interventions improve leadership of surgical trainees, surgeons and surgical teams and why: a realist review protocol

Background

Improving effective leadership of individuals, groups, and healthcare organisations is essential for improving surgical performance and indirectly improving health outcomes for patients. Numerous systematic reviews have been conducted which seek to determine the effectiveness of specific leadership interventions across a range of disciplines and healthcare outcomes. The purpose of this realist review is to systematically synthesise the literature which examines in which context and for whom leadership interventions improve leadership of surgeons, surgical teams, and trainees.

Methods

Several approaches will be used to iteratively search the scientific and grey literature to identify relevant evidence. Selected articles will inform the development of a programme theory that seeks to explain in which context and for whom interventions can improve leadership of surgical trainees, surgeons, and surgical teams. Next, empirical studies will be searched systematically in order to test and, where necessary, refine the theory. Once theoretical saturation has been achieved, recommendations for advancing leadership in surgery will be developed. Stakeholder and patient and public consultations will contribute to the development of the programme theory. The review will be written up according to the Realist And Meta-narrative Evidence Synthesis: Evolving Standards publication standards. No ethical review will be required for the conduct of this realist review.

Discussion

The knowledge gained from this review will provide evidence-based guidance for those planning or designing leadership interventions in surgery. The recommendations will help policymakers, educationalists, healthcare providers, and those delivering or planning leadership development programmes across the surgical disciplines to design interventions that are acceptable to the surgical community and successful in improving surgical leadership.PROSPERO registration: CRD42021230709.

The Impact of the COVID-19 Pandemic on Adolescents: An Opportunity to Build Resilient Systems

The impact of the COVID-19 pandemic on adolescents is significant. Educational progress and mental health, in particular, have been negatively affected. Among youth from vulnerable communities, pre-existing academic and health disparities have been exacerbated. Youth outcomes are often attributed to individual resilience - or lack thereof; in this paper, we describe how failure to adapt and effectively cope at the system level (ie, lack of system resilience) is implicated in the current dual educational and mental crisis. We describe opportunities to make our systems more nimble and better-equipped to support youth moving forward.

Digital Intergenerational Program to Reduce Loneliness and Social Isolation Among Older Adults: Realist Review

BACKGROUND

There is a compelling need for an innovative and creative approach to promote social connectedness among older adults to optimize their well-being and quality of life. One possible solution may be through a digital intergenerational program.

OBJECTIVE

This realist review aimed to identify existing digital intergenerational programs that were used to reduce loneliness or social isolation among older adults and analyze them in terms of strategy, context, mechanisms, and outcomes.

METHODS

We performed a realist review with an extensive search of published and gray literature. For scholarly literature, we searched PubMed, Embase, CINAHL, PsycINFO (Ovid), and Social Sciences Citation Index databases for articles published between January 2000 to August 2020. A grey literature search was performed using the Google search engine, and the search was completed in May 2021. We included programs that evaluated digital intergenerational programs for older adults, which described outcomes of loneliness or social isolation. We included quantitative, mixed methods, and qualitative studies, as well as relevant theoretical papers, policy documents, and implementation documents. The studies were appraised based on their relevance and rigor. We synthesized the available evidence from the literature into Strategy-Context-Mechanism-Outcome (S-C-M-O) configurations to better understand what, when, and how programs work.

RESULTS

A total of 31 documents reporting 27 digital intergenerational programs were reviewed. Our final results identified 4 S-C-M-O configurations. For S-C-M-O configuration 1, we found that for community-dwelling older adults, provision of access to and training in digital technology may increase older adults' self-efficacy in digital devices and therefore increase the use of digital communication with family. In S-C-M-O configuration 2, digital psychosocial support and educational interventions from nurses were found to be useful in reducing loneliness among community-dwelling older adults. In S-C-M-O configuration 3, a video call with a student or family was found to reduce loneliness among older adults residing in long-term residential care facilities. Finally, for S-C-M-O configuration 4, we found that behavioral activation provided through videoconferencing by a lay coach may be useful in reducing loneliness among older adults who are lonely. However, as almost half (11/27, 41%) of the included programs only reported quantitative results, this review focused on screening the discussion section of publications to identify author opinions or any qualitative information to elucidate the mechanisms of how programs work.

CONCLUSIONS

This review identified the key strategy, context, and mechanism influencing the success of programs that promote intergenerational interaction through digital means. This review revealed that different strategies should be adopted for different groups of older adults (eg, older adults who are lonely, older adults who reside in long-term residential care facilities, and community-dwelling older adults). The S-C-M-O configurations should be considered when designing and implementing digital intergenerational programs for older adults.

Design suggestions for a persuasive e-coaching application: A study on informal caregivers' needs

Objective

Informal caregivers such as relatives or close friends of patients are essential for caregiving at home. However, caregiving is a complex experience that may affect the caregivers' well-being. Therefore, there is a need to provide support for caregivers, which we address in this article by proposing design suggestions for an e-coaching application. This study identifies the unmet needs of caregivers in Sweden and provides design suggestions for an e-coaching application using the persuasive system design (PSD) model. The PSD model offers a systematic approach to designing IT interventions.

Methods

A qualitative research design was used, and semi-structured interviews were conducted with 13 informal caregivers from different municipalities in Sweden. A thematic analysis was performed to analyze the data. The PSD model was used to map the needs emerging from this analysis to propose design suggestions for an e-coaching application for caregivers.

Results

Six needs were identified, and based on them, we proposed design suggestions for an e-coaching application using the PSD model. These unmet needs are monitoring and guidance, assistance to avail formal care services, access to practical information without being overwhelmed, feeling of community, access to informal support, and grief acceptance. The last two needs could not be mapped using the existing PSD model, resulting in an extended PSD model.

Conclusion

This study revealed the important needs of informal caregivers based on which design suggestions for an e-coaching application were presented. We also proposed an adapted PSD model. This adapted PSD model can be further used for designing digital interventions in caregiving.

Family involvement in psychotherapy for depression in children and adolescents: Systematic review and meta-analysis

PURPOSE

Depressive disorders in children and adolescents have an enormous impact on their general quality of life. There is a clear need to effectively treat depression in this age group. Effects of psychotherapy can be enhanced by involving caregivers. In our systematic review and meta-analysis, we examine for the first time the effects of caregiver involvement in depression-specific interventions for children and adolescents.

METHODS

We included randomized controlled trials examining the effects of interventions for children and adolescents with depression involving their caregivers or families compared to interventions without including caregivers. Primary outcome was the severity of childhood and adolescent depression.

RESULTS

Overall, 19 randomized controlled trials could be included (N = 1553) that were highly heterogeneous regarding outcome measures or the extent of caregiver integration. We were able to include k = 17 studies in our meta-analysis and find a small but significant effect for family-involved interventions against active control conditions without family-involvement at post intervention (α = 0.05, d = 0.34; [0.07; 0.60]; p = .01).

CONCLUSIONS

We detected an overall significant but small effect of family/caregivers' involvement compared to control groups without it. Structured, guideline-based research is urgently needed to identify for which children/adolescents with depression, under what circumstances, and in what form the family should be effectively involved in their psychotherapy.

Appropriate Use and Operationalization of Adherence to Digital Cognitive Behavioral Therapy for Depression and Anxiety in Youth: Systematic Review

BACKGROUND

Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment.

OBJECTIVE

This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes.

METHODS

A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs.

RESULTS

There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this.

CONCLUSIONS

Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence.

TRIAL REGISTRATION

PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram.

Introduction of Technology to Support Young People’s Care and Mental Health—A Rapid Evidence Review

Background

Technology and its use within mental health services has advanced dramatically over recent years. Opportunities for mental health services to utilise technology to introduce novel, effective, and more efficient means of delivering assessment, and treatment are increasing.

Objective

The current rapid-evidence paper reviews evidence regarding the introduction of novel technology to support young people’s mental health and psychological well-being.

Methods

A rapid evidence review was conducted. PSYCHINFO and CINAHL were searched for research articles between 2016 and 2021 that were specific to young people, mental health, and technology developments within this domain. N = 27 studies which explored the introduction, feasibility, and value of technology for mental health purposes were included in a narrative synthesis. Quality or risk of bias analyses were not completed.

Results

Overall, technological advancements in young people’s care were considered positive and engaging for young people. Factors including resources, efficiency of care, engagement, therapeutic effectiveness, ethical considerations, therapeutic alliance, and flexibility were considered within this review. Nevertheless, potential barriers include clinician concerns, socioeconomic factors, and motivation.

Conclusion

Effective and sustained use of technology within young people’s mental health services will depend on the technology’s usability, efficiency, and ability to engage young people. This paper expands on existing research by reviewing a broader range of technology proposed to support young people’s mental health and well-being. This will assist in the application of novel technological advancements by indicating effectiveness, preferences, potential barriers, and recommendations for the feasibility and efficacy of introducing technology into young people’s services.

Gaming My Way to Recovery: A Systematic Scoping Review of Digital Game Interventions for Young People's Mental Health Treatment and Promotion

Nearly all young people use the internet daily. Many youth with mental health concerns, especially since the Covid-19 pandemic, are using this route to seek help, whether through digital mental health treatment, illness prevention tools, or supports for mental wellbeing. Videogames also have wide appeal among young people, including those who receive mental health services. This review identifies the literature on videogame interventions for young people, ages 12-29, and maps the data on game use by those with mental health and substance use problems, focusing on evidence for the capacity of games to support treatment in youth mental health services; how stakeholders are involved in developing or evaluating games; and any potential harms and ethical remedies identified. A systematic scoping review methodology was used to identify and assess relevant studies. A search of multiple databases identified a total of 8,733 articles. They were screened, and 49 studies testing 32 digital games retained. An adapted stepped care model, including four levels, or steps, based on illness manifestation and severity, was used as a conceptual framework for organizing target populations, mental health conditions and corresponding digital games, and study results. The 49 selected studies included: 10 studies (20.4%) on mental health promotion/prevention or education for undiagnosed youth (Step 0: 7 games); 6 studies (12.2%) on at-risk groups or suspected mental problems (Step 1: 5 games); 24 studies (49.0%) on mild to moderate mental conditions (Steps 2-3: 16 games); and 9 studies (18.4%) focused on severe and complex mental conditions (Step 4: 7 games). Two interventions were played by youth at more than one level of illness severity: the SPARX game (Steps 1, 2-3, 4) and Dojo (Steps 2-3 and 4), bringing the total game count to 35 with these repetitions. Findings support the potential integration of digital games in youth services based on study outcomes, user satisfaction, relatively high program retention rates and the potential usefulness of most games for mental health treatment or promotion/prevention. Most studies included stakeholder feedback, and involvement ratings were very high for seven games. Potential harms were not addressed in this body of research. This review provides an important initial repository and evaluation of videogames for use in clinical settings concerned with youth mental health.

Testing the Effectiveness of a Blended Intervention to Reduce Suicidal Ideation among School Adolescents in Chile: A Protocol for a Cluster Randomized Controlled Trial

Suicidal ideation is prevalent in adolescents and is a marker for subsequent psychiatric vulnerability and symptom severity. Literature shows that blended care (integrating online and offline components in a treatment process) could improve the effectiveness and adherence of interventions targeting suicidal ideation in adolescents, but the evidence is inconclusive. Thus, we will test the effectiveness of a blended intervention to reduce suicidal ideation (primary outcome) in school settings using a single-blind two-armed cluster randomized controlled trial (cRCT). The internet-based component corresponds to the Reframe-IT, a program encompassing eight online sessions based on cognitive-behavioral therapy (CBT) principles. The face-to-face intervention will be delivered through four CBT sessions. Additionally, we will assess the effect of the intervention on the following secondary outcomes: suicidal attempts, depressive symptoms, hopelessness, emotional regulation, and problem-solving skills. Primary and secondary outcomes will be assessed at post-intervention, 3-month, 6-month, and 12-month follow-up. Finally, we will explore the mediation role of cognitive, emotional, and behavioral correlates of suicide on the effect of the intervention. Results will inform whether the intervention can reduce suicide among school adolescents and be implemented on a large scale in Chile.

Standardized evaluation of the quality and persuasiveness of mobile health applications for diabetes management

This study evaluates diabetes self-management mobile health applications available from European app stores with respect to quality, concordance with recommended self-management tasks and implementation of persuasive system design principles. The European Play Store and Apple App Store were systematically searched and relevant apps were tested. Two raters independently assessed app quality using the Mobile Application Rating Scale and conducted a content analysis of provided persuasive system design principles and self-management tasks. A total of 2,269 mobile health applications were identified and 120 could be included in the evaluation. The overall quality was rated as moderate M = 3.20 (SD = 0.39, min = 2.31, max = 4.62), with shortcomings in the subcategories of engagement (M = 2.80, SD = 0.67) and information quality (M = 2.26, SD = 0.48). Scientific evidence is available for 8% of the apps. The reviewed apps implemented a median of three persuasive system design principles (range 0-15) and targeted a median of 4.5 (range 1-8) self-management tasks, however, with a lack of information about psychosocial coping strategies. Most available diabetes self-management apps lack a scientific evidence base. Persuasive system design features are underrepresented and may form a promising tool to improve app quality. Furthermore, the interaction of physical and behavioral health should be improved in existing diabetes self-management mobile health applications.

Feasibility and potential efficacy of a guided internet- and mobile-based CBT for adolescents and young adults with chronic medical conditions and comorbid depression or anxiety symptoms (youthCOACHCD): a randomized controlled pilot trial

Background

Adolescents and young adults (AYA) with a chronic medical condition show an increased risk for developing mental comorbidities compared to their healthy peers. Internet- and mobile-based cognitive behavioral therapy (iCBT) might be a low-threshold treatment to support affected AYA. In this randomized controlled pilot trial, the feasibility and potential efficacy of youthCOACH_CD, an iCBT targeting symptoms of anxiety and depression in AYA with chronic medical conditions, was evaluated.

Methods

A total of 30 AYA (M_age 16.13; SD= 2.34; 73% female), aged 12-21 years either suffering from cystic fibrosis, juvenile idiopathic arthritis or type 1 diabetes, were randomly assigned to either a guided version of the iCBT youthCOACH_CD (IG, n=15) or to a waitlist control group (CG, n=15), receiving an unguided version of the iCBT six months post-randomization. Participants of the IG and the CG were assessed before (t0), twelve weeks after (t1) and six months after (t2) randomization. Primary outcome was the feasibility of the iCBT. Different parameters of feasibility e.g. acceptance, client satisfaction or potential side effects were evaluated. First indications of the possible efficacy with regard to the primary efficacy outcome, the Patient Health Questionnaire Anxiety and Depression Scale, and further outcome variables were evaluated using linear regression models, adjusting for baseline values.

Results

Regarding feasibility, intervention completion was 60%; intervention satisfaction (M = 25.42, SD = 5.85) and perceived therapeutic alliance (M = 2.83, SD = 1.25) were moderate and comparable to other iCBTs. No patterns emerged regarding subjective and objective negative side effects due to participation in youthCOACH_CD. Estimates of potential efficacy showed between group differences, with a potential medium-term benefit of youthCOACH_CD (β = -0.55, 95%CI: -1.17; 0.07), but probably not short-term (β = 0.20, 95%CI: -0.47; 0.88).

Conclusions

Our results point to the feasibility of youthCOACH_CD and the implementation of a future definitive randomized controlled trial addressing its effectiveness and cost-effectiveness. Due to the small sample size, conclusions are premature, however, further strategies to foster treatment adherence should be considered.

Trial registration

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trials Register (ID: DRKS00016714, 25/03/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03134-3.

LovesCompany: evaluating the safety and feasibility of a mental health-focused online community for adolescents

Background: Adolescents are at risk for mental health (MH) disorders but are unlikely to seek services and may be reluctant to talk about their MH. An anonymous, online MH-focused community could help reduce suffering. However, online forums can also promote negative behaviours such as cyberbullying. This study aimed to evaluate the safety and feasibility of an online community - LovesCompany - to improve MH outcomes for adolescents.Methods: American adolescents (14-17 years) were recruited through social media. Eligible participants were randomised to LovesCompany or a placebo MH resource site. Outcomes were assessed every other week for six months, and at twelve months. Multilevel models assessed group differences in depression, anxiety, and suicidal ideation. A subgroup of participants participated in qualitative interviews.Results: Participants (N = 202) were mostly female (70%), White non-Hispanic (69%), and cisgender (80%). There were no instances of inappropriate behaviour such as bullying or posting explicit content. Symptoms for both groups improved over time. Participants appreciated hearing others' experiences and valued the opportunity to offer support.Conclusion: Although adolescents are often resistant to MH treatment, they appear to be interested in anonymous, online, MH-focused conversation, and can benefit from giving and seeking support. Finding a balance between an appealing user experience, ethical considerations, and resource needs is challenging.

Tranquility: An adaptation co-design and fidelity evaluation of an internet-based cognitive-behavioural therapy (iCBT) program for anxiety and depression

Background

Internet-based cognitive behavioral therapy (iCBT) is a necessary step toward increasing the accessibility of mental health services. Yet, few iCBT programs have been evaluated for their fidelity to the therapeutic principles of cognitive behavioral therapy (CBT) or usability standards. In addition, many existing iCBT programs do not include treatments targeting both anxiety and depression, which are commonly co-occurring conditions.

Objective

This study aims to evaluate the usability of Tranquility—a novel iCBT program for anxiety—and its fidelity to CBT principles. This study also aims to engage in a co-design process to adapt Tranquility to include treatment elements for depression.

Methods

CBT experts (n=6) and mental health–informed peers (n=6) reviewed the iCBT program Tranquility. CBT experts assessed Tranquility’s fidelity to CBT principles and were asked to identify necessary interventions for depression by using 2 simulated client case examples. Mental health–informed peers engaged in 2 co-design focus groups to discuss adaptations to the existing anxiety program and the integration of interventions for depression. Both groups completed web-based surveys assessing the usability of Tranquility and the likelihood that they would recommend the program.

Results

The CBT experts’ mean rating of Tranquility’s fidelity to CBT principles was 91%, indicating a high fidelity to CBT. Further, 5 out of 6 CBT experts and all mental health–informed peers (all participants: 11/12, 88%) rated Tranquility as satisfactory, indicating that they may recommend Tranquility to others, and they rated its usability highly (mean 76.56, SD 14.07). Mental health–informed peers provided suggestions on how to leverage engagement with Tranquility (eg, adding incentives and notification control).

Conclusions

This preliminary study demonstrated the strong fidelity of Tranquility to CBT and usability standards. The results highlight the importance of involving stakeholders in the co-design process and future opportunities to increase engagement.

A Cognitive Behavioral Therapy-, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial

Background

Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues.

Objective

This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions.

Methods

Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale.

Results

Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (−4.6; P<.001), Spence Child Anxiety Scale (−9.6; P=.005), and the Likert visual analog scales (−2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up.

Conclusions

This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial.

Trial Registration

Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443

Feasibility and Acceptability of "Cuida tu Ánimo" (Take Care of Your Mood): An Internet-Based Program for Prevention and Early Intervention of Adolescent Depression in Chile and Colombia

The rapid internet penetration in Latin American countries has made it possible to implement digital mental health interventions. “Cuida tu Ánimo” (Take Care of Your Mood) is an internet-based program for the prevention and early intervention of depression in adolescents. A pilot study was conducted in Chile and Colombia to study the feasibility and acceptability of the program and estimate its effects. There were 199 participants (53.3% women; mean age = 14.8 years, SD = 1.0) recruited from two schools in Chile and two schools in Colombia. Qualitative and quantitative methods were applied for data collection and analyses. Although the levels of acceptance were moderate to high across all variables, adherence was lower than expected. The participants deemed important for an intervention of this type offered a higher level of interaction with team members through internet-based and face-to-face activities. Post-intervention outcomes show a reduction in depressive and anxious symptoms in adolescents in Chile, while there were no significant changes in the level of symptomatology in adolescents in Colombia. The women used the program more than the men. Results show the need to improve the intervention by increasing its levels of customization and developing strategies to achieve better adherence. The contradictory results of the program in Chile and Colombia suggest the importance of other variables beyond the content of the intervention, such as the setting or context of the intervention.

Usage activity, perceived usefulness, and satisfaction in a web-based acceptance and commitment therapy program among Finnish ninth-grade adolescents

Understanding adolescent usage activity and experiences in web-based psychological intervention programs helps in developing universal programs that can be adopted for promotion of adolescent well-being and prevention of mental health problems. This study examined the usage activity, perceived usefulness (i.e., learning of mindfulness, acceptance and value-related skills), and program satisfaction of 157 Finnish ninth-grade adolescents, who participated in a school-based five-week universal acceptance and commitment therapy web intervention called Youth Compass. Individual and growth environment-related antecedents were measured before the five-week intervention, adolescents' usage activity during the intervention, and perceived usefulness and satisfaction after the intervention. The results showed that female adolescents and adolescents with high self-regulation were more active program users and had more positive experiences of the program. Most of the adolescents used the program on at least a moderate level and perceived it to be moderately or highly useful and satisfactory. Four subgroups of adolescents were identified based on their usage activity, perceived usefulness, and satisfaction: adolescents in the satisfied group (41%) had average activity and high perceived usefulness and intervention satisfaction, the dissatisfied group (18%) had low activity and very low perceived usefulness and intervention satisfaction, the active group (8%) had very high activity and average perceived usefulness and intervention satisfaction, and the moderate group (33%) had average activity, perceived usefulness and intervention satisfaction. Gender, academic achievement, closeness to mother and teacher, and conflict with teacher were significantly related to subgroup membership. The results suggested that adolescent usage activity, perceived usefulness, and satisfaction with the Youth Compass program may to some extent be predicted based on different factors.

Need for Integrated Behavior Health Model in Primary Care

Children and adolescents with clinically concerning behavioral health conditions face several barriers to accessing specialized mental health care. One proposed solution is to improve and expand integrated care provided in the primary health care provider's office. Several strategies can increase pediatrician comfort and willingness to collaborate in diagnosing and treating behavioral health conditions, and increased utilization of new technologies (such as telehealth) are likely to play an increasingly important role in the process.

The Lègami/Legàmi Service-An Experience of Psychological Intervention in Maternal and Child Care during COVID-19

This study provides a descriptive analysis of the Lègami/Legàmi service, a free psychological support service in maternal and childcare, offered through the internet and by telephone that was initiated by the Italian Society of Pediatric Psychology (S.I.P.Ped.) during the COVID-19 medical emergency as an act of solidarity, first independently, and then in collaboration with the Italian Ministry of Health. This paper presents findings related to the "universe" of people who called the toll-free service, from the sociocultural characteristics of the users to the information collected by the professionals during the psychological pathways until human satisfaction was achieved. We provide a retrospective description of an experience that took place between April and June 2020, and which involved users of the maternal-infant area calling from the whole Italy. (1) Methods: The aims of this study were to investigate the configuration of the indicators identified and to detect the possible correlations between them in the sample. There were 193 users who took advantage of the Service, 160 of whom continued beyond the reception service; it is this group that we report the findings from here. The tool used was a form reporting access to care and interventions, and the resulting data underwent a content analysis and the indicators were subject to non-parametric statistical analysis to analyze differences and relationships. (2) Results: There were many correlations among the indicators that revealed a high prevalence of calls due to personal motivations and requests for support, which later allowed users to gain a greater understanding of the underlying problems they were facing. The professionals running the service noticed a prevalence of weaknesses attributable to the negative emotions of its users, alongside a presence of cognitive and relational resources. The professionals' interventions, which can be characterized by a prevalence of social support, psychological rehabilitation, and psychoeducation, achieved outcomes of redefining users' relationships with themselves and others. All of the service's users have expressed a high level of satisfaction with it. (3) Discussion: Our results revealed the protective and transformative effects of the service for its users and the underlying importance of having an easily accessible psychological support system in place during emergencies, like the recent pandemic. In conditions like these, the great value of a remote support service should be noted, and despite its limitations, assures its own efficacy when a medical emergency precludes closer in-person forms of psychological assistance.

Pragmatic Quasi-Experimental Controlled Trial Evaluating the Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders

Depression is a major problem in youth mental health. Current treatment is on average effective, but adolescents are hesitant to seek help. Blended treatment could lower the barriers to seeking treatment. Evidence on effectiveness is, however, scarce. The present pragmatic quasi-experimental controlled trial aimed to compare the outcomes of blended cognitive behavioral therapy (CBT) to face-to-face CBT and treatment as usual. A total of 129 adolescents with clinical depression (82.2% female), aged 13–22 (M = 16.60, SD = 2.03) received blended CBT, face-to-face CBT or treatment as usual. Clinical diagnosis, depressive symptoms, and secondary outcomes were assessed at baseline, post-intervention, and six-months follow-up. Participants receiving blended CBT were, compared to participants receiving face-to-face CBT and treatment as usual, evenly likely to be in remission from their depressive disorder at post-intervention and at six-month follow-up. Depressive symptoms decreased significantly over time in all three conditions, and changes were not significantly different between conditions. Other secondary outcomes (suicide risk, internalizing and externalizing symptoms, severity of depression, and global functioning) did not differ between treatment conditions at post-intervention and six-month follow-up. Since there was no evidence for favorable outcomes for face-to-face therapies above blended CBT, blended CBT may also be an effective treatment format in clinical practice.

Involving patients' perspective in the development of an internet- and mobile-based CBT intervention for adolescents with chronic medical conditions: Findings from a qualitative study

OBJECTIVE

A user-centered approach is critical for increasing the adherence to and effectiveness of an internet- and mobile-based intervention program. Therefore, potential future intervention users were involved in the development of an internet- and mobile-based cognitive behavioral therapy program (iCBT) for adolescents and young adults (AYA) with chronic medical conditions and comorbid symptoms of anxiety or depression. We aimed to identify challenges and coping strategies of the intended target group, as well as their needs and preferred intervention characteristics for an iCBT program.

METHODS

Twenty AYA (aged 14-20, 60% females) with either type 1 diabetes (55%), juvenile idiopathic arthritis (25%) or cystic fibrosis (20%) were interviewed in condition-specific focus groups (4-11 participants per group) either via videoconferencing or face-to-face. Transcript verbatim data was analyzed using content analysis.

RESULTS

Frequently reported disease-specific burdens were among others fear of disease progression, non-acceptance of disease and stressful incidents related to and aversions against medical therapy. Most frequently reported coping strategies included, seeking social support and accepting the disease. Recommendations for the content of an iCBT for comorbid symptoms of anxiety and depression comprised: dealing with disease-related fears and getting advice on health-promoting lifestyles. iCBT characteristics considered preferable by participants were: providing individual feedback by a real-person; implementation of a feature to monitor treatment progress; youthful and varied content presentation; time per session not exceeding 1 h; non-involvement of parents. A mobile-based reminder feature was considered useful, and individual tailoring and self-determination of iCBT content was considered desirable.

CONCLUSIONS

The findings highlight important patient perspectives and age-specific recommendations which can help design more optimal iCBT interventions for AYA with chronic medical conditions.

An enhanced psychological mindset intervention to promote adolescent wellbeing within educational settings: A feasibility randomized controlled trial

OBJECTIVE

This randomized controlled trial feasibility study aimed to investigate a single-session mindset intervention, incorporating third-wave constructs, within educational settings as a universal tool to promote emotional wellbeing.

METHOD

Eighty adolescents (age M = 16.63) were randomized to the 30-min computer intervention or a usual curriculum waitlist. Outcome measures were administered at baseline, posttreatment, 4-week, and 8-week follow-ups.

RESULTS

Student feedback about the intervention and trial procedure was mainly positive. Participants engaged with the intervention content and data were suggestive of possible small-large intervention effects for targeted mechanisms of personality mindset and psychological flexibility. Between-group differences over time across wellbeing outcomes of self-compassion, self-esteem, low mood, and anxiety also yielded some promising results, though assessments of reliable change were less clear. No harm was reported.

CONCLUSIONS

The intervention and study design were deemed feasible, though areas for improvement were noted. A full-scale trial to determine effectiveness is warranted.

Online narrative exposure therapy for parents of children with neurodevelopmental disabilities suffering from posttraumatic stress symptoms - study protocol of a randomized controlled trial

BACKGROUND

Parents of children with intellectual and neurodevelopmental disorders (IDD) often experience traumatic events in the care of their children. This leads to comparatively high numbers of mental health problems such as posttraumatic stress disorder (PTSD) in those parents. Intervention approaches for parents of children with IDD are scarce and many parents remain without support.

OBJECTIVE

This study aims to test the feasibility and efficacy of online Narrative Exposure Therapy (eNET) with parents of children with IDD.

METHODS

The study follows a randomized waitlist-control design. eNET is an exposure-based PTSD intervention and includes 8-12 90-minute sessions. All sessions will be conducted via video calls with trained paraprofessionals. We aim to include 50 parents, approximately 25 in the immediate intervention group and 25 in the waitlist group. Waitlist participants will receive the same intervention after a three-month wait period. All participants need to either fulfill full or subclinical PTSD symptoms according to DSM-5. Feasibility and efficacy of the intervention will be measured with pre, post, and 2 and 6 months follow-up surveys focusing on PTSD symptoms. Secondary outcomes include other health-related outcomes such as physical symptoms, depression symptoms, anxiety symptoms and functionality.

CONCLUSIONS

The proposed study allows us to test the feasibility and efficacy of eNET in a sample of parents of children with IDD. There are so far no published studies on the evidence of eNET; this study is one of the first randomized controlled trials investigating the feasibility and efficacy of eNET and therefore will have implications on further research and practice.Clinical trial registration: NCT04385927Date and version identifier: 22 July 2021.

Breathing exercises in people with COPD: A realist review

AIMS

To determine the theoretical framework that explains the mechanisms of the success of breathing exercise interventions in people with chronic obstructive pulmonary disease.

DESIGN

A realist review.

DATA SOURCES

Seven bibliographic databases and the grey literature were searched from 2015-January 2020 to identify the studies of breathing exercises.

REVIEW METHODS

The evaluation criteria of realist review and the mixed method appraisal tool were both used to evaluate the included studies. We extracted and integrated the context-mechanism-outcome strings of each study to form the theoretical framework.

RESULTS

Six theoretical mechanisms that affected the success of the intervention were articulated: Wide acceptance of training methods, Integration of the intervention with life, Self-management of the participants, Confidence in controlling symptoms, Participation and support of practitioners, Motivation for intervention. Conversely, the other two mechanisms including the gap between implementation and training and the duration of the intervention, had negative impacts on the implementation of breathing exercises.

CONCLUSION

This review updates and expands the previous literature review on the impact of breathing exercises in people and provides researchers and clinical practitioners with theoretical mechanisms to ensure that the interventions achieve expected effects.

IMPACT

When formulating or selecting breathing exercise interventions, our theoretical framework will guide researchers and clinical practitioners to ensure that the intervention will have practical effects.

Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis

Background

There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development.

Objective

This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom.

Methods

Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls.

Results

A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found.

Conclusions

Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects.

Trial Registration

International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184

The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review

BACKGROUND

Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses.

OBJECTIVE

This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses.

METHODS

A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance.

RESULTS

Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features.

CONCLUSIONS

More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

An Internet-Based Cognitive Behavioral Program for Adolescents With Anxiety: Pilot Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy (ICBT) is a treatment approach recently developed and studied to provide frontline treatment to adolescents with anxiety disorders.

OBJECTIVE

This study aimed to pilot procedures and obtain data on methodological processes and intervention satisfaction to determine the feasibility of a definitive randomized controlled trial (RCT) to test the effectiveness of a self-managed ICBT program, Breathe (Being Real, Easing Anxiety: Tools Helping Electronically), for adolescents with anxiety concerns.

METHODS

This study employed a two-arm, multisite, pilot RCT. Adolescents aged 13 to 17 years with a self-identified anxiety concern were recruited online from health care settings and school-based mental health care services across Canada between April 2014 and May 2016. We compared 8 weeks of ICBT with ad hoc telephone and email support (Breathe experimental group) to access to a static webpage listing anxiety resources (control group). The primary outcome was the change in self-reported anxiety from baseline to 8 weeks (posttreatment), which was used to determine the sample size for a definitive RCT. Secondary outcomes were recruitment and retention rates, a minimal clinically important difference (MCID) for the primary outcome, intervention acceptability and satisfaction, use of cointerventions, and health care resource use, including a cost-consequence analysis.

RESULTS

Of the 588 adolescents screened, 94 were eligible and enrolled in the study (49 adolescents were allocated to Breathe and 45 were allocated to the control group). Analysis was based on 74% (70/94) of adolescents who completed baseline measures and progressed through the study. Enrolled adolescents were, on average, 15.3 years old (SD 1.2) and female (63/70, 90%). Retention rates at 8 weeks were 28% (13/46; Breathe group) and 58% (24/43; control group). Overall, 39% (14/36) of adolescents provided feedback on completion of the Breathe program. Adolescents' scores on a satisfaction survey indicated a moderate level of satisfaction. All but one adolescent indicated that Breathe was easy to use and they understood all the material presented. The most frequent barrier identified for program completion was difficulty in completing exposure activities. The power analysis indicated that 177 adolescents per group would be needed to detect a medium effect size (d=0.3) between groups in a definitive trial. Data for calculating an MCID or conducting a cost-consequence analysis were insufficient due to a low response rate at 8 weeks.

CONCLUSIONS

Adolescents were moderately satisfied with Breathe. However, program adjustments will be needed to address attrition and reduce perceived barriers to completing key aspects of the program. A definitive RCT to evaluate the effectiveness of the program is feasible if protocol adjustments are made to improve recruitment and retention to ensure timely study completion and increase the completeness of the data at each outcome measurement time point.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02059226; http://clinicaltrials.gov/ct2/show/NCT02059226.

Planning for child and adolescent mental health interventions in a rural district of South Africa: a situational analysis

Objective: The aim of this study was to conduct a situational analysis as part of formative work to inform the development of community-based mental health services for children and adolescents at a district level. The purpose of the situational analysis was to determine the current state of child and adolescent mental health (CAMH), the available resources for CAMH, the range of services provided, and the existing pathways to CAMH care in a low-resource district with a view to developing a district mental health plan to improve access to CAMH services. Methods: Data for this situational analysis was collected from a rural district in the KwaZulu-Natal province using mixed methods. The qualitative component explored various stakeholders' (n = 26) perspectives using semi-structured interviews. The quantitative data for the study was collected using an adaptation of the situation analysis tool developed by the PRIME consortium. Results: The findings revealed the need to strengthen all the basic building blocks of the health system due to the weaknesses identified in the current CAMH care system in the district. The result of the situational analysis revealed that the provision of CAMH services in the district is sparse, uncoordinated, and not prioritised. Discussion: The findings of the study highlighted a severe shortage of specialised CAMH services in the district, poor integration of CAMH services into primary health care, and at the community platform there are deficits in the integrated school health programme. Further, the lack of a coordinated intersectoral collaborative system and well-defined referral pathways were revealed. Conclusion: The study highlights various challenges facing CAMH services at the Amajuba district. While these are not new, the study contributes to our understanding of the district level factors that may hinder the development of a district CAMH plan.

Adherence to e-mental health among youth: Considerations for intervention development and research design

E-mental health programmes have great potential to provide young people with access to mental health support. However, it is commonly reported that adherence to these programmes is low. Low adherence can be problematic, particularly if young people do not receive the full benefits of a programme. In a research trial setting, non-adherence to treatment recommendations can prevent researchers from drawing strong conclusions about effectiveness. Although adherence has been recognised as an issue in need of attention, many of the reviews available are focused on adults and lack clear direction towards what strategies to employ. This paper presents a broad review of the adherence literature, focusing on factors associated with improving adherence to e-mental health among youth. Our view on the key elements to improve adherence identified from the existing literature are presented, and key recommendations for e-mental health intervention design are provided. These include: developing and communicating adherence guidelines based on individuals’ needs and symptom severity, including customisable features to provide a tailored experience and promote a sense of agency, including engagement checks and adopting a user-centred approach by utilising strategies such as co-design. This paper provides guidance to intervention designers and researchers by outlining recommendations and considerations for intervention development and research design.

A Weekly, Evidence-Based Health Letter for Caregivers (90Second Caregiver): Usability Study

Background

Informal caregivers are family members or close friends who provide unpaid help to individuals with acute or chronic health conditions so that they can manage daily life tasks. The greatest source of health information is the internet for meeting the needs of caregivers. However, information on the internet may not be scientifically valid, it may be written in language that is difficult to read, and is often in very large doses. 90Second Caregiver is a health letter whose aim is to disseminate knowledge to caregivers in a user-friendly, weekly format, in order to improve their wellbeing.

Objective

The main objective was to test a sample of 90Second Caregiver health letters in order to assess their usability and to optimize the design and content of the health letters.

Methods

Usability research themes were assessed using semi-structured phone interviews, incorporating the Think Aloud method with retrospective questioning.

Results

Usability was assessed in the context of five main themes: understandability and learnability, completeness, relevance, and quality and credibility of the health letter content, as well as design and format. Caregivers generally provided positive feedback regarding the usability of the letters. The usability feedback was used to refine 90Second Caregiver in order to improve the design and content of the series. Based on the results of this study, it may be of maximum benefit to target the series towards individuals who are new to caregiving or part-time caregivers, given that these caregivers of the sample found the letters more useful and relevant and had the most positive usability experiences.

Conclusions

The findings assisted in the improvement of the 90Second Caregiver template, which will be used to create future health letters and refine the letters that have already been created. The findings have implications for who the 90Second Caregiver series should be targeting (ie, newer or part-time caregivers) in order to be maximally impactful in improving mental health and wellbeing-related outcomes for caregivers, such as self-efficacy and caregiving knowledge. The results of this study may be generalizable to the examination of other electronic health information formats, making them valuable to future researchers testing the usability of health information products. In addition, the methods used in this study are useful for usability hypothesis generation. Lastly, our 90Second delivery approach can generate information useful for a set of similar products (eg, weekly health letters targeted towards other conditions/populations).

Examining the Usage, User Experience, and Perceived Impact of an Internet-Based Cognitive Behavioral Therapy Program for Adolescents With Anxiety: Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) increases treatment access for adolescents with anxiety; however, completion rates of iCBT programs are typically low. Understanding adolescents' experiences with iCBT, what program features and changes in anxiety (minimal clinically important difference [MCID]) are important to them, may help explain and improve iCBT program use and impact.

OBJECTIVE

Within a randomized controlled trial comparing a six-session iCBT program for adolescent anxiety, Being Real, Easing Anxiety: Tools Helping Electronically (Breathe), with anxiety-based resource webpages, we aimed to (1) describe intervention use among adolescents allocated to Breathe or webpages and those who completed postintervention assessments (Breathe or webpage respondents); (2) describe and compare user experiences between groups; and (3) calculate an MCID for anxiety and explore relationships between iCBT use, experiences, and treatment response among Breathe respondents.

METHODS

Enrolled adolescents with self-reported anxiety, aged 13 to 19 years, were randomly allocated to Breathe or webpages. Self-reported demographics and anxiety symptoms (Multidimensional Anxiety Scale for Children-2nd edition [MASC-2]) were collected preintervention. Automatically-captured Breathe or webpage use and self-reported symptoms and experiences (User Experience Questionnaire for Internet-based Interventions) were collected postintervention. Breathe respondents also reported their perceived change in anxiety (Global Rating of Change Scale [GRCS]) following program use. Descriptive statistics summarized usage and experience outcomes, and independent samples t tests and correlations examined relationships between them. The MCID was calculated using the mean MASC-2 change score among Breathe respondents reporting somewhat better anxiety on the GRCS.

RESULTS

Adolescents were mostly female (382/536, 71.3%), aged 16.6 years (SD 1.7), with very elevated anxiety (mean 92.2, SD 18.1). Intervention use was low for adolescents allocated to Breathe (mean 2.2 sessions, SD 2.3; n=258) or webpages (mean 2.1 visits, SD 2.7; n=278), but was higher for Breathe (median 6.0, range 1-6; 81/258) and webpage respondents (median 2.0, range 1-9; 148/278). Total user experience was significantly more positive for Breathe than webpage respondents (P<.001). Breathe respondents reported program design and delivery factors that may have challenged (eg, time constraints and program support) or facilitated (eg, demonstration videos, self-management activities) program use. The MCID was a mean MASC-2 change score of 13.8 (SD 18.1). Using the MCID, a positive treatment response was generated for 43% (35/81) of Breathe respondents. Treatment response was not correlated with respondents' experiences or use of Breathe (P=.32 to P=.88).

CONCLUSIONS

Respondents reported positive experiences and changes in their anxiety with Breathe; however, their reports were not correlated with program use. Breathe respondents identified program design and delivery factors that help explain their experiences and use of iCBT and inform program improvements. Future studies can apply our measures to compare user experiences between internet-based interventions, interpret treatment outcomes and improve treatment decision making for adolescents with anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02970734 https://clinicaltrials.gov/ct2/show/NCT02970734.

Feasibility of implementing mobile technology-delivered mental health treatment in routine adult sickle cell disease care

Sickle cell disease (SCD) is a severe hemoglobinopathy characterized by acute and chronic pain. Sufferers of the disease, most of whom are underrepresented minorities, are at increased risk for mental health disorders. The purpose of this study is to test the acceptability and implementation of a computerized cognitive behavioral therapy (cCBT) intervention, Beating the Blues, to improve depression, anxiety, and pain in patients with SCD. Adults with SCD and significant symptoms of depression (Patient Health Questionnaire [PHQ-9] score ≥ 10) or anxiety (Generalized Anxiety Disorder Scale [GAD-7] score ≥ 10) were eligible to participate and be randomized to either receive eight sessions of cCBT with care coach support or treatment as usual. Participants reported daily pain and mood symptoms using a mobile diary app. Depression, anxiety, and pain symptoms were assessed at 1, 3, and 6 months. Thirty patients were enrolled: 18 to cCBT, and 12 to control. The cCBT intervention was feasible to implement in clinical settings and acceptable to participants. Patients in the cCBT arm reported a marginally greater decrease in depression at 6 months (-3.82, SE = 1.30) than those in the control group (-0.50, SE = 1.60; p = .06). There were no significant effects of treatment on anxiety; however, cCBT was associated with improved daily pain reported via a mobile diary app (p = .014). cCBT, delivered via mobile device, is a feasible strategy to provide mental health care to adults living with SCD. cCBT was acceptable to the target population; was able to be implemented in real-world, nonideal conditions; and has the potential to improve patient-reported outcomes.

[The Importance of Social Exchange for Internet-based Eating Disorder Prevention]

The Importance of Social Exchange for Internet-based Eating Disorder Prevention Internet-based interventions have the potential to complement routine care mental health services. Yet, dissemination and implementation into routine care is challenging and often fails. From a public health point of view, facilitating access to care and dissemination of prevention have great potential to reduce eating disorder related suffering in the general population. In order to exploit that potential effective strategies to involve users in internet-based prevention are of utmost importance. User-behaviors of N = 980 predominantly female (80 %) participants with an average age of 19.4 years (SD = 7.0) of an internet-based intervention for the prevention of eating disorders (ProYouth) were analyzed. Specifically, differences in users' pathways between early and late phases of participation were compared in order to identify patterns of program utilization that are associated with elevated adherence. During their first login, users explore all modules of the platform. Enduring participation is characterized by increased usage of the modules that offer social exchange with other participants, i. e. the forums and the chat. Static modules, e. g., psychoeducation, are rarely accessed after the first login. Additionally, enduring users were more often female, older, and displayed higher levels of psychological impairment (ps < .001). The results support the relevance of social exchange for the adherence in internet-based interventions for the prevention of eating disorders.

Moderated Online Social Therapy: Viewpoint on the Ethics and Design Principles of a Web-Based Therapy System

The modern omnipresence of social media and social networking sites (SNSs) brings with it a range of important research questions. One of these concerns the impact of SNS use on mental health and well-being, a question that has been pursued in depth by scholars in the psychological sciences and the field of human-computer interaction. Despite this attention, the design choices made in the development of SNSs and the notion of well-being employed to evaluate such systems require further scrutiny. In this viewpoint paper, we examine the strategic design choices made in our development of an enclosed SNS for young people experiencing mental ill-health in terms of ethical and persuasive design and in terms of how it fosters well-being. In doing so, we critique the understanding of well-being that is used in much of the existing literature to make claims about the impact of a given technology on well-being. We also demonstrate how the holistic concept of eudaimonic well-being and ethical design of SNSs can complement one another.

Evaluating the Efficacy of Internet-Delivered Cognitive Behavioral Therapy Blended With Synchronous Chat Sessions to Treat Adolescent Depression: Randomized Controlled Trial

Background

Depression is a common and serious problem among adolescents, but few seek or have access to therapy. Internet-delivered cognitive behavioral therapies (ICBTs), developed to increase treatment access, show promise in reducing depression. The inclusion of coach support in treatment is desired and may be needed.

Objective

The aim of this study was to determine the efficacy of an ICBT protocol blended with weekly real-time therapist sessions via chat; blended treatment, for adolescent depression, including major depressive episode (MDE). The protocol has previously been evaluated in a controlled study.

Methods

In a two-arm randomized controlled trial, adolescents 15 to 19 years of age were recruited through a community setting at the national level in Sweden (n=70) and allocated to either 8 weeks of treatment or to minimal attention control. Depression was assessed at baseline, at posttreatment, and at 12 months following treatment (in the intervention group). The primary outcome was self-reported depression level as measured with the Beck Depression Inventory II at posttreatment. The intervention was offered without the need for parental consent.

Results

Over two weeks, 162 adolescents registered and completed the baseline screening. Eligible participants (n=70) were on average 17.5 years of age (SD 1.15), female (96%, 67/70), suffered from MDE (76%, 53/70), had no previous treatment experience (64%, 45/70), and reported guardian(s) to be aware about their depression state (71%, 50/70). The average intervention completion was 74% (11.8 of 16 modules and sessions). Following the treatment, ICBT participants demonstrated a significant decrease in depression symptoms compared with controls (P<.001), corresponding to a large between-group effect (intention-to-treat analysis: d=0.86, 95% CI 0.37-1.35; of completer analysis: d=0.99, 95% CI 0.48-1.51). A significant between-group effect was observed in the secondary depression outcome (P=.003); clinically significant improvement was found in 46% (16/35) of ICBT participants compared with 11% (4/35) in the control group (P=.001).

Conclusions

The results are in line with our previous study, further demonstrating that adolescents with depression can successfully be engaged in and experience significant improvement following ICBT blended with therapist chat sessions. Findings on participants’ age and baseline depression severity are of interest in relation to used study methods.

Trial Registration

ClinicalTrials.gov NCT02363205; https://clinicaltrials.gov/ct2/show/NCT02363205

Use of the Chatbot "Vivibot" to Deliver Positive Psychology Skills and Promote Well-Being Among Young People After Cancer Treatment: Randomized Controlled Feasibility Trial

BACKGROUND

Positive psychology interventions show promise for reducing psychosocial distress associated with health adversity and have the potential to be widely disseminated to young adults through technology.

OBJECTIVE

This pilot randomized controlled trial examined the feasibility of delivering positive psychology skills via the Vivibot chatbot and its effects on key psychosocial well-being outcomes in young adults treated for cancer.

METHODS

Young adults (age 18-29 years) were recruited within 5 years of completing active cancer treatment by using the Vivibot chatbot on Facebook messenger. Participants were randomized to either immediate access to Vivibot content (experimental group) or access to only daily emotion ratings and access to full chatbot content after 4 weeks (control). Created using a human-centered design process with young adults treated for cancer, Vivibot content includes 4 weeks of positive psychology skills, daily emotion ratings, video, and other material produced by survivors, and periodic feedback check-ins. All participants were assessed for psychosocial well-being via online surveys at baseline and weeks 2, 4, and 8. Analyses examined chatbot engagement and open-ended feedback on likability and perceived helpfulness and compared experimental and control groups with regard to anxiety and depression symptoms and positive and negative emotion changes between baseline and 4 weeks. To verify the main effects, follow-up analyses compared changes in the main outcomes between 4 and 8 weeks in the control group once participants had access to all chatbot content.

RESULTS

Data from 45 young adults (36 women; mean age: 25 [SD 2.9]; experimental group: n=25; control group: n=20) were analyzed. Participants in the experimental group spent an average of 74 minutes across an average of 12 active sessions chatting with Vivibot and rated their experience as helpful (mean 2.0/3, SD 0.72) and would recommend it to a friend (mean 6.9/10; SD 2.6). Open-ended feedback noted its nonjudgmental nature as a particular benefit of the chatbot. After 4 weeks, participants in the experimental group reported an average reduction in anxiety of 2.58 standardized t-score units, while the control group reported an increase in anxiety of 0.7 units. A mixed-effects models revealed a trend-level (P=.09) interaction between group and time, with an effect size of 0.41. Those in the experimental group also experienced greater reductions in anxiety when they engaged in more sessions (z=-1.9, P=.06). There were no significant (or trend level) effects by group on changes in depression, positive emotion, or negative emotion.

CONCLUSIONS

The chatbot format provides a useful and acceptable way of delivering positive psychology skills to young adults who have undergone cancer treatment and supports anxiety reduction. Further analysis with a larger sample size is required to confirm this pattern.

Utilisation of tools to facilitate cross-border communication during international food safety events, 1995-2019: a realist synthesis protocol

INTRODUCTION

Efficient communication and coordination between countries is needed for prevention, detection and response to international food safety events. While communication tools exist, current evidence suggests that they are only effective within certain contexts and only cover certain geographic areas. There is a need to unpack and explore the mechanisms of how and in what context such communication tools and their components are effective at facilitating international communication and coordination to keep food safe and mitigate the burden of foodborne disease around the globe.

METHODS AND ANALYSIS

A realist synthesis will be undertaken to understand how and why certain processes and structures of communication tools, used during international food safety events, influence their utility and effectiveness according to different contextual factors. The focus of this review is explanatory and aims to develop and refine theory regarding how contextual factors trigger specific processes and mechanisms to produce outcomes. Using the realist context-mechanism-outcome configuration of theory development, a range of sources have been used to develop the initial programme theory, including the author's experience, a scoping review of published papers and grey literature and input from an expert reference committee. To support, expand or refute the initial theory, data will be synthesised from published literature and input from the expert reference committee.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review as it does not involve primary research. However, it will be conducted according to the appropriate ethical standards of accuracy, utility, usefulness, accountability, feasibility and propriety. The RAMESES publication standards will be followed to report the findings of this review. On completion, the final manuscript will be shared with members of the FAO/WHO International Food Safety Authorities Network (INFOSAN) and published in a peer-reviewed journal.

Tailoring Persuasive Electronic Health Strategies for Older Adults on the Basis of Personal Motivation: Web-Based Survey Study

Background

Persuasive design, in which the aim is to change attitudes and behaviors by means of technology, is an important aspect of electronic health (eHealth) design. However, selecting the right persuasive feature for an individual is a delicate task and is likely to depend on individual characteristics. Personalization of the persuasive strategy in an eHealth intervention therefore seems to be a promising approach.

Objective

This study aimed to develop a method that allows us to model motivation in older adults with respect to leading a healthy life and a strategy for personalizing the persuasive strategy of an eHealth intervention, based on this user model.

Methods

We deployed a Web-based survey among older adults (aged >60 years) in the Netherlands. In the first part, we administered an adapted version of the revised Sports Motivation Scale (SMS-II) as input for the user models. Then, we provided each participant with a selection of 5 randomly chosen mock-ups (out of a total of 11), each depicting a different persuasive strategy. After showing each strategy, we asked participants how much they appreciated it. The survey was concluded by addressing demographics.

Results

A total of 212 older adults completed the Web-based survey, with a mean age of 68.35 years (SD 5.27 years). Of 212 adults, 45.3% were males (96/212) and 54.7% were female (116/212). Factor analysis did not allow us to replicate the 5-factor structure for motivation, as targeted by the SMS-II. Instead, a 3-factor structure emerged with a total explained variance of 62.79%. These 3 factors are intrinsic motivation, acting to derive satisfaction from the behavior itself (5 items; Cronbach alpha=.90); external regulation, acting because of externally controlled rewards or punishments (4 items; Cronbach alpha=.83); and a-motivation, a situation where there is a lack of intention to act (2 items; r=0.50; P<.001). Persuasive strategies were appreciated differently, depending on the type of personal motivation. In some cases, demographics played a role.

Conclusions

The personal type of motivation of older adults (intrinsic, externally regulated, and/or a-motivation), combined with their educational level or living situation, affects an individual’s like or dislike for a persuasive eHealth feature. We provide a practical approach for profiling older adults as well as an overview of which persuasive features should or should not be provided to each profile. Future research should take into account the coexistence of multiple types of motivation within an individual and the presence of a-motivation.

Computer-Assisted Cognitive-Behavioral Therapy to Treat Adolescents With Depression in Primary Health Care Centers in Santiago, Chile: A Randomized Controlled Trial

Introduction: Evidence from developed countries shows the efficacy of computer-assisted cognitive-behavioral therapy (cCBT) in addressing adolescent depression in home and/or school settings. This paper presents the results of a randomized controlled trial (RCT) of a brief therapist-guided cCBT intervention for adolescent depression in resource-constrained primary health care (PHC) settings. Material and methods: A multicenter, two-arm parallel-group, individually RCT with a 1:1 allocation ratio assigned 216 depressed adolescents (aged 15-19) attending four PHC centers in a low-income municipality of Santiago, Chile, to receive eight weekly face-to-face therapist-guided cCBT sessions by study therapists (N = 108), or to receive an enhanced usual care (EUC) intervention by trained PHC psychologists, encouraged to adhere to the national clinical guidelines for the management of depression (N = 108). Both groups received pharmacotherapy concordant with these guidelines. The primary outcome was the Beck Depression Inventory (BDI) at 4 months post-randomization, to assess depressive symptoms. BDI at 6 months post-randomization was a secondary outcome. Additional measures included patients' compliance, and satisfaction with different treatment components, at 6 months post-randomization. Main Results: The adjusted difference in mean BDI score between groups was -3.75 (95% CI -6.23 to -1.28; p = 0.003) at 4 months post-randomization. At 6 months post-randomization, the adjusted difference in mean BDI score between groups was -2.31 (95% CI -4.89 to 0.27; p = 0.078). The effect size was small-to-medium at 4 months post-randomization, d = 0.39 (0.12 to 0.67), and small and non-significant at 6 months post-randomization d = 0.29 (-0.00 to 0.59). Adolescents in the experimental treatment group were significantly more satisfied with treatment, with the PHC centers' facilities, with the psychological care received, and with non-professional staff than those in the comparator treatment group. Discussion: A brief therapist-guided cCBT eight-session intervention improves the response of depressed adolescents attending PHC centers at 4 months post-randomization. At 6 months post-randomization, the differences of between groups were not significant. Future research may focus on exploring strategies to sustain and increase response. Clinical trial registration: www.ClinicalTrials.gov, identifier NCT01862913 and URL: https://clinicaltrials.gov/ct2/show/NCT01862913.