Evaluating a brief, internet-based intervention for co-occurring depression and problematic alcohol use in young people: protocol for a randomized controlled trial

Diagnosing major depressive disorder and substance use disorder using the electronic health record: A preliminary validation study

Background

One mechanism to examine if major depressive disorder (MDD) is related to the development of substance use disorder (SUD) is by leveraging naturalistic data available in the electronic health record (EHR). Rules for data extraction and variable construction linked to psychometrics validating their use are needed to extract data accurately.

Objective

We propose and validate a methodologic framework for using EHR variables to identify patients with MDD and non-nicotine SUD.

Methods

Proxy diagnoses and index dates of MDD and/or SUD were established using billing codes, problem lists, patient-reported outcome measures, and prescriptions. Manual chart reviews were conducted for the 1-year period surrounding each index date to determine (1) if proxy diagnoses were supported by chart notes and (2) if the index dates accurately captured disorder onset.

Results

The results demonstrated 100% positive predictive value for proxy diagnoses of MDD. The proxy diagnoses for SUD exhibited strong agreement (Cohen's kappa of 0.84) compared to manual chart review and 92% sensitivity, specificity, positive predictive value, and negative predictive value. Sixteen percent of patients showed inaccurate SUD index dates generated by EHR extraction with discrepancies of over 6 months compared to SUD onset identified through chart review.

Conclusions

Our methodology was very effective in identifying patients with MDD with or without SUD and moderately effective in identifying SUD onset date. These findings support the use of EHR data to make proxy diagnoses of MDD with or without SUD.

Online interventions for people hospitalized for deliberate self-harm and problematic alcohol use: Lessons learned from the iiAIM trial

Deliberate self-harm and suicide affect all age groups, sexes, and regions, and their prevention is a global health priority. Acute alcohol misuse and chronic alcohol misuse are strong, modifiable risk factors, and Internet interventions aiming to reduce alcohol misuse and comorbid mental health problems (e.g., depression) are a promising and effective treatment modality. The research team aimed to evaluate the feasibility and effectiveness of an Internet-based comorbidity intervention primarily aiming to reduce alcohol consumption, and secondarily to reduce readmission for deliberate self-harm and improve psychological outcomes among people hospitalized for deliberate self-harm who also engage in problematic alcohol use. However, due to several barriers to recruitment, the trial could not be completed and was discontinued. The authors present a "Lessons Learned" discussion and describe the Internet Intervention for Alcohol Improvement (iiAIM) trial, discuss the key barriers experienced by the research team, and recommend potential solutions that may help future trials in this area.

Surveying the Role of Analytics in Evaluating Digital Mental Health Interventions for Transition-Aged Youth: Scoping Review

BACKGROUND

Consumer-facing digital health interventions provide a promising avenue to bridge gaps in mental health care delivery. To evaluate these interventions, understanding how the target population uses a solution is critical to the overall validity and reliability of the evaluation. As a result, usage data (analytics) can provide a proxy for evaluating the engagement of a solution. However, there is paucity of guidance on how usage data or analytics should be used to assess and evaluate digital mental health interventions.

OBJECTIVE

This review aimed to examine how usage data are collected and analyzed in evaluations of mental health mobile apps for transition-aged youth (15-29 years).

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. A systematic search was conducted on 5 journal databases using keywords related to usage and engagement, mental health apps, and evaluation. A total of 1784 papers from 2008 to 2019 were identified and screened to ensure that they included analytics and evaluated a mental health app for transition-aged youth. After full-text screening, 49 papers were included in the analysis.

RESULTS

Of the 49 papers included in the analysis, 40 unique digital mental health innovations were evaluated, and about 80% (39/49) of the papers were published over the past 6 years. About 80% involved a randomized controlled trial and evaluated apps with information delivery features. There were heterogeneous findings in the concept that analytics was ascribed to, with the top 3 being engagement, adherence, and acceptability. There was also a significant spread in the number of metrics collected by each study, with 35% (17/49) of the papers collecting only 1 metric and 29% (14/49) collecting 4 or more analytic metrics. The number of modules completed, the session duration, and the number of log ins were the most common usage metrics collected.

CONCLUSIONS

This review of current literature identified significant variability and heterogeneity in using analytics to evaluate digital mental health interventions for transition-aged youth. The large proportion of publications from the last 6 years suggests that user analytics is increasingly being integrated into the evaluation of these apps. Numerous gaps related to selecting appropriate and relevant metrics and defining successful or high levels of engagement have been identified for future exploration. Although long-term use or adoption is an important precursor to realizing the expected benefits of an app, few studies have examined this issue. Researchers would benefit from clarification and guidance on how to measure and analyze app usage in terms of evaluating digital mental health interventions for transition-aged youth. Given the established role of adoption in the success of health information technologies, understanding how to abstract and analyze user adoption for consumer digital mental health apps is also an emerging priority.

Study protocol for a systematic review of evidence for digital interventions for comorbid excessive drinking and depression in community-dwelling populations

INTRODUCTION

Excessive drinking and depression are frequently comorbid and make a substantial contribution to the global non-communicable disease burden. A range of effective interventions and treatments exist for either excessive drinking or depression alone, including a positive emerging evidence base for the use of digital interventions. Computerised and/or smartphone delivered advice could provide flexible, coordinated support for patients with comorbid excessive drinking and depression. However, to date, no systematic review of the evidence has been conducted focused on the effectiveness of digital interventions for this specific comorbid population. This systematic review will identify and evaluate the effectiveness of digital interventions for reducing comorbid excessive drinking and depression in community-dwelling populations.

METHODS AND ANALYSIS

We will search MEDLINE, The Cochrane Library, CENTRAL, CINAHL, PsycINFO, ERIC and SCI from inception to end of July 2019 for randomised controlled trials that evaluate any personalised digital intervention for comorbid excessive drinking and depression and published in any language. Primary outcomes will be changes in quantity of alcohol consumed and depressive symptoms. Screening, data extraction and risk of bias assessment will be undertaken independently by two reviewers, with disagreements resolved through discussion. Meta-analytic methods will be used to synthesise the data collected relating to the primary outcomes of interest.

ETHICS AND DISSEMINATION

As a systematic review, ethical approval is not needed. Findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

CRD42019130134.

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

Background

Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT) have been delivered face-to-face. However, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based CBT and IPT involve therapeutic content, interaction between the user and the system, and different technological features embedded into the online program (eg, multimedia). Studies of Internet-based CBT and IPT for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the treatment conditions that influence therapy outcomes is important to designing and evaluating these novel therapies.

Objective

Our aim was to examine the technological and program delivery features of Internet-based CBT and IPT for adolescent depression and to document their potential relation to treatment outcomes and program use.

Methods

We performed a realist synthesis. We started with an extensive search of published and gray literature. We included intervention studies that evaluated Internet-based CBT or IPT for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the Mixed-Methods Appraisal Tool to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how Internet-based CBT and IPT, as technology-based systems, influence the attitudes and behaviors of system users. PSD components described for the therapies were linked to reported outcomes using a cross-case comparison method and thematic synthesis.

Results

We identified 19 Internet-based CBT programs in 59 documents. Of those, 71% (42/59) were of moderate to high quality. The PSD features surface credibility (competent “look and feel”), dialogue support (online program + in-person support), liking and similarity (esthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction, and adherence, as well as symptom and functional impairments.

Conclusions

When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction, and depression-related outcomes. Testing of these features using hypothesis-driven dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness.

Online and social networking interventions for the treatment of depression in young people: a systematic review

BACKGROUND

Major depression accounts for the greatest burden of all diseases globally. The peak onset of depression occurs between adolescence and young adulthood, and for many individuals, depression displays a relapse-remitting and increasingly severe course. Given this, the development of cost-effective, acceptable, and population-focused interventions for depression is critical. A number of online interventions (both prevention and acute phase) have been tested in young people with promising results. As these interventions differ in content, clinician input, and modality, it is important to identify key features (or unhelpful functions) associated with treatment outcomes.

OBJECTIVE

A systematic review of the research literature was undertaken. The review was designed to focus on two aspects of online intervention: (1) standard approaches evaluating online intervention content in randomized controlled designs (Section 1), and (2) second-generation online interventions and services using social networking (eg, social networking sites and online support groups) in any type of research design (Section 2).

METHODS

Two specific literature searches were undertaken. There was no date range specified. The Section 1 search, which focused on randomized controlled trials, included only young people (12-25 years) and yielded 101 study abstracts, of which 15 met the review inclusion criteria. The Section 2 search, which included all study design types and was not restricted in terms of age, yielded 358 abstracts, of which 22 studies met the inclusion criteria. Information about the studies and their findings were extracted and tabulated for review.

RESULTS

The 15 studies identified in Section 1 described 10 trials testing eight different online interventions, all of which were based on a cognitive behavioral framework. All but one of the eight identified studies reported positive results; however, only five of the 15 studies used blinded interviewer administered outcomes with most trials using self-report data. Studies varied significantly in presentation of intervention content, treatment dose, and dropout. Only two studies included moderator or clinician input. Results for Section 2 were less consistent. None of the Section 2 studies reported controlled or randomized designs. With the exception of four studies, all included participants were younger than 25 years of age. Eight of the 16 social networking studies reported positive results for depression-related outcomes. The remaining studies were either mixed or negative. Findings for online support groups tended to be more positive; however, noteworthy risks were identified.

CONCLUSIONS

Online interventions with a broad cognitive behavioral focus appear to be promising in reducing depression symptomology in young people. Further research is required into the effectiveness of online interventions delivering cognitive behavioral subcomponents, such as problem-solving therapy. Evidence for the use of social networking is less compelling, although limited by a lack of well-designed studies and social networking interventions. A range of future social networking therapeutic opportunities are highlighted.