Internet-Delivered Early Interventions for Individuals Exposed to Traumatic Events: Systematic Review

Towards accurate screening and prevention for PTSD (2-ASAP): protocol of a longitudinal prospective cohort study

BACKGROUND

Effective preventive interventions for PTSD rely on early identification of individuals at risk for developing PTSD. To establish early post-trauma who are at risk, there is a need for accurate prognostic risk screening instruments for PTSD that can be widely implemented in recently trauma-exposed adults. Achieving such accuracy and generalizability requires external validation of machine learning classification models. The current 2-ASAP cohort study will perform external validation on both full and minimal feature sets of supervised machine learning classification models assessing individual risk to follow an adverse PTSD symptom trajectory over the course of 1 year. We will derive these models from the TraumaTIPS cohort, separately for men and women.

METHOD

The 2-ASAP longitudinal cohort will include N = 863 adults (N = 436 females, N = 427 males) who were recently exposed to acute civilian trauma. We will include civilian victims of accidents, crime and calamities at Victim Support Netherlands; and who were presented for medical evaluation of (suspected) traumatic injuries by emergency transportation to the emergency department. The baseline assessment within 2 months post-trauma will include self-report questionnaires on demographic, medical and traumatic event characteristics; potential risk and protective factors for PTSD; PTSD symptom severity and other adverse outcomes; and current best-practice PTSD screening instruments. Participants will be followed at 3, 6, 9, and 12 months post-trauma, assessing PTSD symptom severity and other adverse outcomes via self-report questionnaires.

DISCUSSION

The ultimate goal of our study is to improve accurate screening and prevention for PTSD in recently trauma-exposed civilians. To enable future large-scale implementation, we will use self-report data to inform the prognostic models; and we will derive a minimal feature set of the classification models. This can be transformed into a short online screening instrument that is user-friendly for recently trauma-exposed adults to fill in. The eventual short online screening instrument will classify early post-trauma which adults are at risk for developing PTSD. Those at risk can be targeted and may subsequently benefit from preventive interventions, aiming to reduce PTSD and relatedly improve psychological, functional and economic outcomes.

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.

Early intervention in post-traumatic stress disorder without exposure to trauma memories using internet-delivered cognitive therapy: A pilot case series

OBJECTIVES

Trauma-focussed psychological interventions are the treatments of choice for post-traumatic stress disorder (PTSD). As many clinical services receive high demand for PTSD interventions, strategies to improve treatment efficiency are needed. Some people seek help in the early phase post-trauma, including as soon as the first few months. It is unclear whether all components of trauma-focussed CBT are needed in this initial stage. Providing brief intervention in this early phase without work on trauma memories may be feasible and effective. This service evaluation study describes a case series of five participants experiencing PTSD following recent traumas.

METHODS

Participants completed a shortened 6-week form of Internet-delivered Cognitive Therapy for PTSD (iCT-PTSD), which used fewer treatment modules and focussed primarily on psychoeducation about PTSD, and two key treatment components, 'reclaiming your life' and trigger discrimination. Unlike the full course of iCT-PTSD, this format did not include working directly with trauma memories.

RESULTS

The intervention was associated with large reductions in symptoms of PTSD, depression and anxiety at the 6-week timepoint, which were maintained at 3-month follow-up. Scores on the composite PTSD measure showed an average reduction of 91% between baseline and end of follow-up. One client required an extension to the weekly phase of treatment and received further treatment modules. All were discharged after follow-up and did not require further treatment.

CONCLUSIONS

The findings provide preliminary evidence that this briefer format of iCT-PTSD was of benefit for those seeking support following recent traumas. Further examination in a larger controlled study is required.

Evidence Synthesis of Digital Interventions to Mitigate the Negative Impact of the COVID-19 Pandemic on Public Mental Health: Rapid Meta-review

Background

Accumulating evidence suggests the COVID-19 pandemic has negative effects on public mental health. Digital interventions that have been developed and evaluated in recent years may be used to mitigate the negative consequences of the pandemic. However, evidence-based recommendations on the use of existing telemedicine and internet-based (eHealth) and app-based mobile health (mHealth) interventions are lacking.

Objective

The aim of this study was to investigate the theoretical and empirical base, user perspective, safety, effectiveness, and cost-effectiveness of digital interventions related to public mental health provision (ie, mental health promotion, prevention, and treatment of mental disorders) that may help to reduce the consequences of the COVID-19 pandemic.

Methods

A rapid meta-review was conducted. The MEDLINE, PsycINFO, and CENTRAL databases were searched on May 11, 2020. Study inclusion criteria were broad and considered systematic reviews and meta-analyses that investigated digital tools for health promotion, prevention, or treatment of mental health conditions and determinants likely affected by the COVID-19 pandemic.

Results

Overall, 815 peer-reviewed systematic reviews and meta-analyses were identified, of which 83 met the inclusion criteria. Our findings suggest that there is good evidence on the usability, safety, acceptance/satisfaction, and effectiveness of eHealth interventions. Evidence on mHealth apps is promising, especially if social components (eg, blended care) and strategies to promote adherence are incorporated. Although most digital interventions focus on the prevention or treatment of mental disorders, there is some evidence on mental health promotion. However, evidence on process quality, cost-effectiveness, and long-term effects is very limited.

Conclusions

There is evidence that digital interventions are particularly suited to mitigating psychosocial consequences at the population level. In times of physical distancing, quarantine, and restrictions on social contacts, decision makers should develop digital strategies for continued mental health care and invest time and efforts in the development and implementation of mental health promotion and prevention programs.

Mobile Insight in Risk, Resilience, and Online Referral (MIRROR): Psychometric Evaluation of an Online Self-Help Test

BACKGROUND

Most people who experience a potentially traumatic event (PTE) recover on their own. A small group of individuals develops psychological complaints, but this is often not detected in time or guidance to care is suboptimal. To identify these individuals and encourage them to seek help, a web-based self-help test called Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event and provides direct feedback to the user.

OBJECTIVE

The goal of this study was to assess MIRROR's use, examine its psychometric properties (factor structure, internal consistency, and convergent and divergent validity), and evaluate how well it classifies respondents into different outcome categories compared with reference measures.

METHODS

MIRROR was embedded in the website of Victim Support Netherlands so visitors could use it. We compared MIRROR's outcomes to reference measures of PTSD symptoms (PTSD Checklist for DSM-5), depression, anxiety, stress (Depression Anxiety Stress Scale-21), psychological resilience (Resilience Evaluation Scale), and positive mental health (Mental Health Continuum Short Form).

RESULTS

In 6 months, 1112 respondents completed MIRROR, of whom 663 also completed the reference measures. Results showed good internal consistency (interitem correlations range .24 to .55, corrected item-total correlations range .30 to .54, and Cronbach alpha coefficient range .62 to .68), and convergent and divergent validity (Pearson correlations range -.259 to .665). Exploratory and confirmatory factor analyses (EFA+CFA) yielded a 2-factor model with good model fit (CFA model fit indices: χ219=107.8, P<.001, CFI=.965, TLI=.948, RMSEA=.065), conceptual meaning, and parsimony. MIRROR correctly classified respondents into different outcome categories compared with the reference measures.

CONCLUSIONS

MIRROR is a valid and reliable self-help test to identify negative (PTSD complaints) and positive outcomes (psychosocial functioning and resilience) of PTEs. MIRROR is an easily accessible online tool that can help people who have experienced a PTE to timely identify psychological complaints and find appropriate support, a tool that might be highly needed in times like the coronavirus pandemic.

Early Psychological Intervention After Rape: A Feasibility Study

Rape is the most common trauma leading to post-traumatic stress disorder (PTSD) among women, with a conditioned prevalence of up to 50%. PTSD is considered to be a lethal condition associated with increased risk of suicide, drug- and alcohol dependence, neurological- and vascular problems, as well as sick leave. Given the scope of this problem, novel and swiftly delivered interventions for this large vulnerable population are clearly warranted. One previous trial conducted in the United States (N = 137) showed that an adapted brief version of prolonged exposure (PE) to the fearful memory of the event and situations, provided in the immediate aftermath after trauma (<72 h after a traumatic event), was effective in reducing early PTSD symptoms in rape victims. The aims of the present study were to adapt the brief PE protocol to a Swedish context and investigate its feasibility and delivery in 10 executive patients recruited at the Emergency Clinic for Rape Victims in Stockholm. Ten participants were provided with three sessions of early PE with overall successful results in terms of session attendance, home-work compliance, and also symptom reduction of PTSD and depressive symptoms. However, only a fraction of the screened patients at the Emergency Clinic (5.2%) were eligible to be included in the study, where the majority (40%) were excluded due to the time criteria of 72 h. In this article, we will present detailed results of the intervention and elaborate on how to increase feasibility of preventive interventions for rape victims. In the current form, providing PE with the strict time criteria was not feasible in the clinical setting that constitutes the Emergency Department for rape.

A Mobile and Web-Based Self-Directed Complementary and Integrative Health Program for Veterans and Their Partners (Mission Reconnect): Protocol for a Mixed-Methods Randomized Controlled Trial

Background

Complementary and integrative health (CIH) is a viable solution to PTSD and chronic pain. Many veterans believe CIH can be performed only by licensed professionals in a health care setting. Health information technology can bring effective CIH to veterans and their partners.

Objective

This paper describes the rationale, design, and methods of the Mission Reconnect protocol to deliver mobile and Web-based complementary and integrative health programs to veterans and their partners (eg, spouse, significant other, caregiver, or family member).

Methods

This three-site, 4-year mixed-methods randomized controlled trial uses a wait-list control to determine the effects of mobile and Web-based CIH programs for veterans and their partners, or dyads. The study will use two arms (ie, treatment intervention arm and wait-list control arm) in a clinical sample of veterans with comorbid pain and posttraumatic stress disorder, and their partners. The study will evaluate the effectiveness and perceived value of the Mission Reconnect program in relation to physical and psychological symptoms, global health, and social outcomes.

Results

Funding for the study began in November 2018, and we are currently in the process of recruitment screening and data randomization for the study. Primary data collection will begin in May 2019 and continue through May 2021. Projected participants per site will be 76 partners/dyads, for a total of 456 study participants. Anticipated study results will be published in November 2022.

Conclusions

This work highlights innovative delivery of CIH to veterans and their partners for treatment of posttraumatic stress disorder and chronic pain.

Trial Registration

ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772 (Archived by WebCite at http://www.webcitation.org/77Q2giwtw)

International Registered Report Identifier (IRRID)

PRR1-10.2196/13666