A systematic review and economic evaluation of computerised cognitive behaviour therapy for depression and anxiety

The 100 most-cited articles on bibliotherapy: a bibliometric analysis

Bibliotherapy is an important part of art therapy and many publications regarding bibliotherapy have been published in the past. However, there has none about the scientometric study to systematically analyze the development and emerging research trends on bibliotherapy. Therefore, we performed a scientometric investigation to describe trends of this theme. All publications related to bibliotherapy published from 1980 to 2020 were identified and selected from Science Citation Index Expanded, Social Sciences Citation Index, and Arts & Humanities Citation Index of Web of Science Core Collection. VOSviewer was used to create collaborative network plots of countries, institutions, and authors and to perform cluster analysis of keywords. A total of 703 articles were searched, and we retrieved the 100 most cited articles published by 146 institutions from 15 countries in 57 academic journals. The United States occupied a leading position in the field of bibliotherapy and Linköping University was the most productive institution. Journal of Consulting and Clinical Psychology was the most productive journal. Andersson G, Carlbring P, and Cuijpers P may have an important influence on bibliotherapy research. The applications in depression, anxiety, panic disorder, insomnia, and aphasia are the hot themes. This scientometric review provided a comprehensive understanding of the bibliotherapy research using quantitative and qualitative methods, which can provide references for researchers in the bibliotherapy field. As investigators continue to work, we look forward to the development of bibliotherapy efficacy and the implementation form and steps.

Apparent Lack of Benefit of Combining Repetitive Transcranial Magnetic Stimulation with Internet-Delivered Cognitive Behavior Therapy for the Treatment of Resistant Depression: Patient-Centered Randomized Controlled Pilot Trial

Background: Treatment-resistant depression (TRD) is considered one of the major clinical challenges in the field of psychiatry. An estimated 44% of patients with major depressive disorder (MDD) do not respond to two consecutive antidepressant therapies, and 33% do not respond to up to four antidepressants. Over 15% of all patients with MDD remain refractory to any treatment intervention. rTMS is considered a treatment option for patients with TRD. Likewise, iCBT is evidence-based, symptom-focused psychotherapy recommended for the treatment of TRD. Objective: This study aimed to evaluate the initial comparative clinical effectiveness of rTMS treatment with and without iCBT as an innovative intervention for the treatment of participants diagnosed with TRD. Methods: This study is a prospective two-arm randomized controlled trial. Overall, 78 participants diagnosed with TRD were randomized to one of two treatment interventions: rTMS sessions alone and rTMS sessions plus iCBT. Participants in each group were made to complete evaluation measures at baseline, and 6 weeks (discharge) from treatment. The primary outcome measure was baseline to six weeks change in mean score for the 17-item Hamilton depression rating scale (HAMD-17). Secondary outcomes included mean baseline to six-week changes in the Columbia suicide severity rating scale (CSSRS) for the rate of suicidal ideations, the QIDS-SR16 for subjective depression, and the EQ-5D-5L to assess the quality of health in participants. Results: A majority of the participants were females 50 (64.1%), aged ≥ 40 39 (50.0%), and had college/university education 54 (73.0%). After adjusting for the baseline scores, the study failed to find a significant difference in the changes in mean scores for participants from baseline to six weeks between the two interventions under study on the HAMD-17 scale: F (1, 53) = 0.15, p = 0.70, partial eta squared = 0.003, CSSRS; F (1, 56) = 0.04 p = 0.85, partial eta squared = 0.001, QIDS-SR16 scale; F (1, 53) = 0.04 p = 0.61, partial eta squared = 0.005, and EQ-5D-VAS; F (1, 51) = 0.46 p = 0.50, and partial eta squared = 0.009. However, there was a significant reduction in means scores at week six compared to baseline scores for the combined study population on the HAMD-17 scale (42%), CSSRS (41%), QIDS-SR16 scale (35%), and EQ-VAS scale (62%). Conclusion: This study did not find that combined treatment of TRD with rTMS + iCBT (unguided) was superior to treatment with rTMS alone. Our findings do not support the use of combined treatment of rTMS + iCBT for the management of TRD disorders.

Cost-effectiveness of screening tools for identifying depression in early pregnancy: a decision tree model

Background

Although the effectiveness of screening tools for detecting depression in pregnancy has been investigated, there is limited evidence on the cost-effectiveness. This is vital in providing full information to decision makers. This study aimed to explore the cost-effectiveness of different screening tools to identify depression in early pregnancy compared to no screening.

Methods

A decision tree was developed to model the identification and treatment pathways of depression from the first antenatal appointment to 3-months postpartum using the Whooley questions, the Edinburgh Postnatal Depression Scale (EPDS) and the Whooley questions followed by the EPDS, compared to no screening. The economic evaluation took an NHS and Personal Social Services perspective. Model parameters were taken from a combination of sources including a cross-sectional survey investigating the diagnostic accuracy of screening tools, and other published literature. Cost-effectiveness was assessed in terms of the incremental cost per quality adjusted life years (QALYs). Cost-effectiveness planes and cost-effectiveness acceptability curves were produced using a net-benefit approach based on Monte Carlo simulations of cost-outcome data.

Results

In a 4-way comparison, the Whooley, EPDS and Whooley followed by the EPDS each had a similar probability of being cost-effective at around 30% for willingness to pay values from £20,000–30,000 per QALY compared to around 20% for the no screen option.

Conclusions

All three screening approaches tested had a higher probability of being cost-effective than the no-screen option. In the absence of a clear cost-effectiveness advantage for any one of the three screening options, the choice between the screening approaches could be made on other grounds, such as clinical burden of the screening options. Limitations include data availability and short time horizon, thus further research is needed.

Clinical trials registration

N/A

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08115-x.

Primary care professionals' attitudes towards digital health interventions for common mental disorders: study protocol for a mixed methods systematic review

INTRODUCTION

Mental disorders such as depression are common, and an estimated 264 million people are affected by them throughout the world. In recent years, studies on digital health interventions to treat mental disorders have shown evidence of their efficacy, and interest in using them has increased as a result. In the primary care setting, depression and anxiety are the two most frequently diagnosed and treated mental disorders. When they do not refer them to specialists, primary care professionals such as general practitioners treat patients with mental disorders themselves but have insufficient time to treat them adequately. Furthermore, there is a shortage of psychotherapists and those that exist have long waiting lists for an appointment. The purpose of this mixed methods systematic review is to explore the attitudes of primary care professionals towards the use of digital health interventions in the treatment of patients with mental disorders. Their attitudes will provide an indication whether digital mental health interventions can effectively complement standard care in the primary care setting.

METHODS AND ANALYSIS

We searched for qualitative, quantitative and mixed methods studies published in English, German, Spanish, Russian, French and Dutch after January 2010 for inclusion in the review. The included studies must involve digital mental health interventions conducted via computer and/or mobile devices in the primary care setting. The search was conducted in July 2020 in the following electronic bibliographic databases: MEDLINE, Embase, CINAHL, PsycINFO and Web of Science Core Collection. Two reviewers will independently screen titles, abstracts and full texts and extract data. We will use the 'Integrated methodology' framework to combine both quantitative and qualitative data.

ETHICS AND DISSEMINATION

Ethical approval is not required. We will disseminate the results of the mixed methods systematic review in a peer-reviewed journal and scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42020188879.

Repetitive Transcranial Magnetic Stimulation With and Without Internet-Delivered Cognitive-Behavioral Therapy for the Treatment of Resistant Depression: Protocol for Patient-Centered Randomized Controlled Pilot Trial

BACKGROUND

Major depression is a severe, disabling, and potentially lethal clinical disorder. Only about half of patients respond to an initial course of antidepressant pharmacotherapy. At least 15% of all patients with major depressive disorder (MDD) remain refractory to any treatment intervention. By the time that a patient has experienced 3 definitive treatment failures, the likelihood of achieving remission with the fourth treatment option offered is below 10%. Repetitive transcranial magnetic stimulation (rTMS) is considered a treatment option for patients with MDD who are refractory to antidepressant treatment. It is not currently known if the addition of internet-delivered cognitive-behavioral therapy (iCBT) enhances patients' responses to rTMS treatments.

OBJECTIVE

This study will evaluate the initial comparative clinical effectiveness of rTMS with and without iCBT as an innovative patient-centered intervention for the treatment of participants diagnosed with treatment-resistant depression (TRD).

METHODS

This study is a prospective, two-arm randomized controlled trial. In total, 100 participants diagnosed with resistant depression at a psychiatric care clinic in Edmonton, Alberta, Canada, will be randomized to one of two conditions: (1) enrolment in rTMS sessions alone and (2) enrolment in the rTMS sessions plus iCBT. Participants in each group will complete evaluation measures (eg, recovery, general symptomatology, and functional outcomes) at baseline, 1 month, 3 months, and 6 months. The primary outcome measure will be the mean change to scores on the Hamilton Depression Rating Scale. Patient service utilization data and clinician-rated measures will also be used to gauge patient progress. Patient data will be analyzed with descriptive statistics, repeated measures, and correlational analyses.

RESULTS

We expect the results of the study to be available in 24 months. We hypothesize that participants enrolled in the study who receive rTMS plus iCBT will achieve superior outcomes in comparison to participants who receive rTMS alone.

CONCLUSIONS

The concomitant application of psychotherapy with rTMS has not been investigated previously. We hope that this project will provide us with a concrete base of data to evaluate the practical application and efficacy of using a novel combination of these two treatment modalities (rTMS plus iCBT).

TRIAL REGISTRATION

ClinicalTrials.gov NCT0423965; https://clinicaltrials.gov/ct2/show/NCT04239651.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/18843.

Development of an audio and computer cognitive behavioral therapy for depression in older adults

Background: The purpose of this paper is to discuss the development of two novel technology-based interventions for depression in older adults while comparing older adults' preferences for audio-based and computer-based cognitive behavioral therapy for depressive symptoms. The audio program consisted of eight compact discs and a workbook while the computer program consisted of 11 modules of similar duration provided on a tablet PC. Both interventions consisted of the following topics: 1) introduction, 2) identifying and changing unhelpful thoughts, 3) addressing feelings, 4) relaxation, 5) engaging in pleasant events, 6) assertiveness, and 7) problem-solving. Methods: Fifty-one older adults were recruited from medical settings and rural communities and randomly assigned to an immediate treatment group (computer or audio) with minimal contact or a four-week minimal contact delayed treatment control condition. Results: Participants rated computer-based and audio-based cognitive behavioral therapy fairly equally, with 75% of those who received audio treatment and 85% of those who received computer-based treatment indicating benefits to their mood.Discussion: Computer-based or audio-based cognitive behavioral treatments may be valuable, low-cost modalities to deliver psychotherapy to older adults with depressive symptoms within a health care setting. Both modalities seem to be accepted by older adults.

Stepped Care as an Implementation and Service Delivery Model for Cognitive Behavioral Therapy for Psychosis

Cognitive behavioral therapy for schizophrenia spectrum disorders is an evidence-based treatment that is recommended by United States schizophrenia treatment guidelines. Based on recent estimates, only 0.3% of individuals with a primary psychotic disorder are able to access this treatment in the United States. Stepped care interventions have shown promise as an applied treatment delivery model in other settings and for other psychotherapeutic interventions. The current paper describes how the stepped care model can be applied to CBT for psychosis in the US to increase access to the intervention in community mental health settings by leveraging the multidisciplinary team.

Efficacy of an internet-based self-management intervention for depression or dysthymia - a study protocol of an RCT using an active control condition

BACKGROUND

The treatment of major depressive disorder, a highly prevalent disorder associated with pronounced burden, is a large challenge to healthcare systems worldwide. Internet based self-management interventions seem to be a cost effective way to complement the treatment of depressed patients, but the accumulating evidence is mainly based on the comparison to waitlist controls and treatment as usual, which might lead to an overestimation of effects. Furthermore, studies assessing long-term effects and possible negative outcomes are still rare.

METHODS/DESIGN

The proposed study evaluates the efficacy of the German version of the iFightDepression® tool in comparison to an active control condition. A total of 360 patients with mild to moderate depressive symptoms are included into a two-armed randomized controlled trial. They receive one of two six week interventions; either the iFightDepression® tool or progressive muscle relaxation serving as the control condition. Both intervention groups receive information material, weekly tasks via the internet and regular phone calls as part of the intervention. The primary outcome is change in depressive symptoms after the intervention period, as measured with the Inventory of Depressive Symptomatology. Satisfaction with the program, usability, changes in perceived quality of life, and possible negative effects are assessed as secondary outcomes.

DISCUSSION

This study represents the first randomized controlled trial on the iFightDepression® self-management tool in its German version, aiming at efficacy, but also at providing new insights into so far understudied aspects of E-mental health programs, namely the specificity of the treatment effect compared to an active control condition, it's continuity over a time course of 12 months, and possible negative effects of these internet based interventions.

TRIAL REGISTRATION

International trial-registration took place through the "international clinical trials registry platform" (WHO) with the secondary ID 080-15-09032015. German Clinical Trial Registration: DRKS00009323 (DRKS.de, registered on 25 February 2016).

Systematic review with meta-analysis: online psychological interventions for mental and physical health outcomes in gastrointestinal disorders including irritable bowel syndrome and inflammatory bowel disease

BACKGROUND

Online psychotherapy has been successfully used as supportive treatment in many chronic illnesses. However, there is a lack of evidence on its role in the management of gastrointestinal (GI) diseases.

AIMS

To examine whether online psychological interventions improve mental and physical outcomes in gastrointestinal diseases.

METHODS

We searched CINAHL Plus, MEDLINE, EMBASE, Health Management Information Consortium, PsycINFO, British Nursing Index, Cochrane Library, a specialised register of the IBD/FBD Cochrane Group, MEDLINE (PubMed) WHO International Clinical Trial Registry, ClinicalTrials.gov, and reference lists of all papers included in the review. The Cochrane Risk of Bias Tool was used to assess internal validity. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

We identified 11 publications (encompassing nine studies) meeting inclusion criteria. One study had a high risk of selection bias (allocation concealment), all studies had a high risk of performance and detection bias. Eight studies were included in the meta-analyses (6 on irritable bowel syndrome [IBS] and two on inflammatory bowel disease [IBD]). Online cognitive behavioural therapy (CBT) was shown to significantly improve gastrointestinal symptom-specific anxiety (MD: -8.51, 95% CI -12.99 to -4.04, P = 0.0002) and lessen symptom-induced disability (MD: -2.78, 95% CI -5.43 to -0.12, P = 0.04) in IBS post intervention. There was no significant effect of online CBT on any other outcomes in IBS. No significant effect of online psychotherapy was demonstrated in IBD.

CONCLUSION

There is insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases.

Improving Breast Cancer Survivors' Psychological Outcomes and Quality of Life: Alternatives to Traditional Psychotherapy

Purpose of Review

Breast cancer survivors (BCS) often experience psychological problems and lowered quality of life (QOL). While helpful, psychotherapy is often costly and inaccessible. This review aims to provide practitioners with the latest information on empirically tested interventions among BCS that may be used in lieu of, or in addition to, traditional psychotherapy.

Recent Findings

Recent developments in cancer-related psychological interventions include a focus on facilitating emotional disclosure (e.g., expressive writing), enhancing close relationships (e.g., couples-based interventions), and increasing feasibility and accessibility via online and computer-based intervention programs. These alternatives to psychotherapy offer a number of benefits including cost-effectiveness, personalized adaptability, and ease of implementation.

Summary

Utilizing these interventions as alternatives or supplements to traditional psychotherapy may offer BCS an opportunity to increase their QOL, improve psychosocial outcomes, and find meaning in their cancer experience. Choosing the appropriate intervention requires understanding the unique circumstances for each survivor and their family.

Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis

Objectives Postpartum depression impacts 6.5-12.9% of U.S. women. Postpartum depression is associated with impaired bonding and development, marital discord, suicide, and infanticide. However, the current standard of care is to not screen women for postpartum depression. This study modeled the cost-effectiveness of physicians screening for and treating postpartum depression and psychosis in partnership with a psychiatrist. Methods This study follows a hypothetical cohort of 1000 pregnant women experiencing one live birth over a 2-year time horizon. We used a decision tree model to obtain the outcomes of screening for and treating postpartum depression and psychosis using the Edinburgh Postnatal Depression Scale. We use a Medicaid payer perspective because they cover approximately 50% of births in the U.S. The cost-effectiveness of the intervention is measured in cost per remission achieved and cost per quality-adjusted life-year (QALY) gained. We conducted both deterministic and probabilistic sensitivity analyses. Results Screening for and treating postpartum depression and psychosis produced 29 more healthy women at a cost of $943 per woman. The incremental cost-effectiveness ratios of the intervention branch compared to usual care were $13,857 per QALY gained (below the commonly accepted willingness to pay threshold of $50,000/QALY gained) and $10,182 per remission achieved. These results were robust in both the deterministic and probabilistic sensitivity analyses of input parameters. Conclusions for Practice Screening for and treating postpartum depression is a cost-effective intervention and should be considered as part of usual postnatal care, which aligns with the recently proposed recommendations from the U.S. Preventive Services Task Force.

Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold

BACKGROUND

Cost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence.

OBJECTIVES

(1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes.

METHODS

Earlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs.

RESULTS

The most relevant 'central' threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008-10 mortality). Uncertainty analysis indicates that the probability that the threshold is < £20,000 per QALY is 0.89 and the probability that it is < £30,000 per QALY is 0.97. Additional 'structural' uncertainty suggests, on balance, that the central or best estimate is, if anything, likely to be an overestimate. The health effects of changes in expenditure are greater when PCTs are under more financial pressure and are more likely to be disinvesting than investing. This indicates that the central estimate of the threshold is likely to be an overestimate for all technologies which impose net costs on the NHS and the appropriate threshold to apply should be lower for technologies which have a greater impact on NHS costs.

LIMITATIONS

The central estimate is based on identifying a preferred analysis at each stage based on the analysis that made the best use of available information, whether or not the assumptions required appeared more reasonable than the other alternatives available, and which provided a more complete picture of the likely health effects of a change in expenditure. However, the limitation of currently available data means that there is substantial uncertainty associated with the estimate of the overall threshold.

CONCLUSIONS

The methods go some way to providing an empirical estimate of the scale of opportunity costs the NHS faces when considering whether or not the health benefits associated with new technologies are greater than the health that is likely to be lost elsewhere in the NHS. Priorities for future research include estimating the threshold for subsequent waves of expenditure and outcome data, for example by utilising expenditure and outcomes available at the level of Clinical Commissioning Groups as well as additional data collected on QoL and updated estimates of incidence (by age and gender) and duration of disease. Nonetheless, the study also starts to make the other NHS patients, who ultimately bear the opportunity costs of such decisions, less abstract and more 'known' in social decisions.

FUNDING

The National Institute for Health Research-Medical Research Council Methodology Research Programme.

Development of a technology-based behavioral vaccine to prevent adolescent depression: A health system integration model

Efforts to prevent depression have become a key health system priority. Currently, there is a high prevalence of depression among adolescents, and treatment has become costly due to the recurrence patterns of the illness, impairment among patients, and the complex factors needed for a treatment to be effective. Primary care may be the optimal location to identify those at risk by offering an Internet-based preventive intervention to reduce costs and improve outcomes. Few practical interventions have been developed. The models for Internet intervention development that have been put forward focus primarily on the Internet component rather than how the program fits within a broader context. This paper describes the conceptualization for developing technology based preventive models for primary care by integrating the components within a behavioral vaccine framework. CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training) has been developed and successfully implemented within various health systems over a period of 14 years among adolescents and young adults aged 13-24.

Cost-effectiveness of cognitive behavioral therapy for insomnia comorbid with depression: Analysis of a randomized controlled trial

AIM

Although the efficacy of cognitive behavioral therapy for insomnia has been confirmed, dissemination depends on the balance of benefits and costs. This study aimed to examine the cost-effectiveness of cognitive behavioral therapy for insomnia consisting of four weekly individual sessions.

METHODS

We conducted a 4-week randomized controlled trial with a 4-week follow up in outpatient clinics in Japan. Thirty-seven patients diagnosed as having major depressive disorder according to DSM-IV and suffering from chronic insomnia were randomized to receive either treatment as usual (TAU) alone or TAU plus cognitive behavioral therapy for insomnia. Effectiveness was evaluated as quality-adjusted life years (QALY) over 8 weeks' time, estimated by bootstrapping of the observed total scores of the Hamilton Depression Rating Scale. Direct medical costs for cognitive behavioral therapy for insomnia and TAU were also evaluated. We calculated the incremental cost-effectiveness ratio.

RESULTS

Over the 8 weeks of the study, the group receiving cognitive behavioral therapy for insomnia plus TAU had significantly higher QALY (P = 0.002) than the TAU-alone group with an incremental value of 0.019 (SD 0.006), and had non-significantly higher costs with an incremental value of 254 (SD 203) USD in direct costs. The incremental cost-effectiveness ratio was 13 678 USD (95% confidence interval: -5691 to 71 316). Adding cognitive behavioral therapy for insomnia demonstrated an approximately 95% chance of gaining one more QALY if a decision-maker was willing to pay 60 000 USD, and approximately 90% for 40 000 USD.

CONCLUSION

Adding cognitive behavioral therapy for insomnia is highly likely to be cost-effective for patients with residual insomnia and concomitant depression.

Modelling the cost-effectiveness of preventing major depression in general practice patients

BACKGROUND

The prevention of depression is a key public health policy priority. PredictD is the first risk algorithm for the prediction of the onset of major depression. Our aim in this study was to model the cost-effectiveness of PredictD in depression prevention in general practice (GP).

METHOD

A decision analytical model was developed to determine the cost-effectiveness of two approaches, each of which was compared to treatment as usual (TAU) over 12 months: (1) the PredictD risk algorithm plus a low-intensity depression prevention programme; and (2) a universal prevention programme in which there was no initial identification of those at risk. The model simulates the incidence of depression and disease progression over 12 months and calculates the net monetary benefit (NMB) from the National Health Service (NHS) perspective.

RESULTS

Providing patients with PredictD and a depression prevention programme prevented 15 (17%) cases of depression in a cohort of 1000 patients over 12 months and had the highest probability of being the optimal choice at a willingness to pay (WTP) of £20,000 for a quality-adjusted life year (QALY). Universal prevention was strongly dominated by PredictD plus a depression prevention programme in that universal prevention resulted in less QALYs than PredictD plus prevention for a greater cost.

CONCLUSIONS

Using PredictD to identify primary-care patients at high risk of depression and providing them with a low-intensity prevention programme is potentially cost-effective at a WTP of £20,000 per QALY.

Pilot Study of Implementation of an Internet-Based Depression Prevention Intervention (CATCH-IT) for Adolescents in 12 US Primary Care Practices: Clinical and Management/Organizational Behavioral Perspectives

OBJECTIVE

To explore the implementation of CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral Humanistic and Interpersonal Training), an Internet-based depression intervention program in 12 primary care sites, occurring as part of a randomized clinical trial comparing 2 versions of the intervention (motivational interview + Internet program versus brief advice + Internet program) in 83 adolescents aged 14 to 21 years recruited from February 1, 2007, to November 31, 2007.

METHOD

The CATCH-IT intervention model consists of primary care screening to assess risk, a primary care physician interview to encourage participation, and 14 online modules of Internet training to teach adolescents how to reduce behaviors that increase vulnerability to depressive disorders. Specifically, we evaluated this program from both a management/organizational behavioral perspective (provider attitudes and demonstrated competence) and a clinical outcomes perspective (depressed mood scores) using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, and Maintenance of the intervention).

RESULTS

While results varied by clinic, overall, clinics demonstrated satisfactory reach, efficacy, adoption, implementation, and maintenance of the CATCH-IT depression prevention program. Measures of program implementation and management predicted clinical outcomes at practices in exploratory analyses.

CONCLUSION

Multidisciplinary approaches may be essential to evaluating the impact of complex interventions to prevent depression in community settings. Primary care physicians and nurses can use Internet-based programs to create a feasible and cost-effective model for the prevention of mental disorders in adolescents in primary care settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT00152529 and NCT00145912.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults

BACKGROUND

Anxiety disorders are the most common mental health problems. They are chronic and unremitting. Effective treatments are available, but access to services is limited. Media-delivered behavioural and cognitive behavioural interventions (self-help) aim to deliver treatment with less input from professionals compared with traditional therapies.

OBJECTIVES

To assess the effects of media-delivered behavioural and cognitive behavioural therapies for anxiety disorders in adults.

SEARCH METHODS

Published and unpublished studies were considered without restriction by language or date. The Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR) was searched all years to 1 January 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Complementary searches were carried out on Ovid MEDLINE (1950 to 23 February 2013) and PsycINFO (1987 to February, Week 2, 2013), together with International trial registries (the trials portal of the World Health Organization (ICTRP) and ClinicalTrials.gov). Reference lists from previous meta-analyses and reports of randomised controlled trials were checked, and authors were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials of media-delivered behavioural or cognitive behavioural therapy in adults with anxiety disorders (other than post-traumatic stress disorder) compared with no intervention (including attention/relaxation controls) or compared with face-to-face therapy.

DATA COLLECTION AND ANALYSIS

Both review authors independently screened titles and abstracts. Study characteristics and outcomes were extracted in duplicate. Outcomes were combined using random-effects models, and tests for heterogeneity and for small study bias were conducted. We examined subgroup differences by type of disorder, type of intervention provided, type of media, and recruitment methods used.

MAIN RESULTS

One hundred and one studies with 8403 participants were included; 92 studies were included in the quantitative synthesis. These trials compared several types of media-delivered interventions (with varying levels of support) with no treatment and with face-to-face interventions. Inconsistency and risk of bias reduced our confidence in the overall results. For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants). The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice. Evidence suggested benefit for secondary outcome measures (depression, mental-health related disability, quality of life and dropout), but this evidence was of low to moderate quality. Evidence regarding harm was lacking.

AUTHORS' CONCLUSIONS

Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior. Economic analyses were beyond the scope of this review.Important heterogeneity was noted across trials. Recent interventions for specific problems that incorporate clinician support may be more effective than transdiagnostic interventions (i.e. interventions for multiple disorders) provided with no guidance, but these issues are confounded in the available trials.Although many small trials have been conducted, the generalisability of their findings is limited. Most interventions tested are not available to consumers. Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established. Large, pragmatic trials are needed to evaluate and to maximise the benefits of self-help interventions.

Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data

OBJECTIVE

To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression.

DESIGN

Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care.

SETTING

Primary care and community settings.

PARTICIPANTS

2470 patients with depression.

INTERVENTIONS

Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions).

MAIN OUTCOME MEASURES

Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions.

RESULTS

Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient -0.1 (95% CI -0.19 to -0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant.

CONCLUSIONS

The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

Case study of cognitive behavioural therapy awareness educational programme using blended learning, UK

This paper examined the opportunities as well as challenges in relation to the use of cognitive behavioural therapy (CBT). The opportunities include the increased range of mental health conditions and other disorders where CBT (in isolation or with other interventions) could be effective to address them, as well as policies around workforce education and training that support the expansion of psychological therapies, particularly CBT services. The challenges include the urgent need of heightened awareness among the wider platform of health and social care workers about CBT principles, structure, framework, methods of delivery, wider applications, evaluation and appropriate referral of clients, and stepped model of care. In response to such needs, the paper described CBT awareness educational award at the University of Gloucestershire, UK: the Certificate of Professional Studies in Awareness of Cognitive and Behavioural Therapies Practice delivered at Level III and M level. The challenges associated with the initiation and running of such educational programmes are highlighted, as well as suggestions for the way forward considering the learners', employers' and educational providers' perspectives.

Suitability and acceptability of computerised cognitive behaviour therapy for anxiety disorders in secondary care

OBJECTIVE

To evaluate the suitability and acceptability of computerised cognitive behaviour therapy (CCBT).

METHOD

Participants were patients who had been referred to a secondary care service in the usual manner, and then offered participation in a randomised controlled trial comparing the efficacy of CCBT with a control condition (waitlist) for patients with a current primary diagnosis of generalised anxiety disorder, panic disorder or social phobia. Data were collected regarding the recruitment and retention of patients, and patient ratings (anchored Likert scales) of treatment credibility, treatment satisfaction, treatment acceptability and telephone support.

RESULTS

A total of 1141 referrals were received by the secondary care service. Of the 1141, 748 (66%) were not suitable for the study, 178 (16%) declined to participate and 127 (11%) were not contactable. Therefore, of the 1141 patients referred to the secondary care service, only 88 patients (8%) were eligible and consenting for the study. The single most common reason for patients not being suitable for the study was that the referral was urgent. In a clinical setting where CCBT could be used alongside clinical management, many of these patients may have been suitable for CCBT. Of the patients randomised to treatment (n = 40), 65% completed treatment. Drop-out rates were not significantly different across diagnostic groups. The single most commonly cited reason for not completing treatment was 'too busy'. Patient ratings of treatment were typically favourable (credibility, satisfaction, acceptability and telephone support).

CONCLUSIONS

CCBT was typically rated favourably by patients referred to a secondary care service and randomised to treatment. However, only a small minority of patients was eligible and consenting for the trial. Therefore, while CCBT may be an acceptable treatment, its suitability for secondary care settings remains unclear.

A randomized controlled trial of the Cool Teens CD-ROM computerized program for adolescent anxiety

OBJECTIVE

Computerized cognitive behavioral interventions for anxiety disorders in adults have been shown to be efficacious, but limited data are available on the use of computerized interventions with young persons. Adolescents in particular are difficult to engage in treatment and may be especially suited to computerized technologies. This paper describes the results of a small randomized controlled trial of the Cool Teens program for adolescent anxiety, and examines potential barriers to treatment and user preferences of computerized technology in this population.

METHOD

Forty-three adolescents with a primary diagnosis of anxiety were randomly allocated to the Cool Teens program, a 12-week computerized cognitive-behavioral therapy program for anxiety management, or a 12-week wait list. Effects on symptoms, negative thoughts, and life interference were assessed at post-treatment and 3-month follow-up, based on diagnosis as well as self and maternal report.

RESULTS

Using mixed-model analyses, at post-treatment and follow-up assessments, adolescents in the Cool Teens condition, compared with those on the wait list, were found to have significant reductions in the total number of anxiety disorders, the severity of the primary anxiety disorder, and the average severity for all disorders. These results were matched by significant reductions in mother and child questionnaire reports of anxiety, internalizing symptoms, automatic thoughts, and life interference. Further few barriers to treatment were found, and user preferences indicated that the computerized treatment was well suited to adolescents with anxiety.

CONCLUSIONS

The Cool Teens program is efficacious for treatment of adolescent anxiety. Clinical trial registration information-A randomized controlled trial of the Cool Teens computerized program for anxious adolescents compared with waist list; http://www.anzctr.org.au; ACTRN12611000508976.

The role of self-help in the treatment of mild anxiety disorders in young people: an evidence-based review

Anxiety disorders are the most common mental health problems experienced by young people, and even mild anxiety can significantly limit social, emotional, and cognitive development into adulthood. It is, therefore, essential that anxiety is treated as early and effectively as possible. Young people are unlikely, however, to seek professional treatment for their problems, increasing their chance of serious long-term problems such as impaired peer relations and low self-esteem. The barriers young people face to accessing services are well documented, and self-help resources may provide an alternative option to respond to early manifestations of anxiety disorders. This article reviews the potential benefits of self-help treatments for anxiety and the evidence for their effectiveness. Despite using inclusive review criteria, only six relevant studies were found. The results of these studies show that there is some evidence for the use of self-help interventions for anxiety in young people, but like the research with adult populations, the overall quality of the studies is poor and there is need for further and more rigorous research.

Development and process evaluation of a primary care internet-based intervention to prevent depression in emerging adults

BACKGROUND

Primary care is a potential setting for implementation of depression prevention interventions using cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). The purpose of this study was to develop and conduct a process evaluation of a primary care/ Internet-based intervention that addresses key dissemination barriers in a community setting.

METHOD

We used an interdisciplinary team of investigators in a multistep intervention development process among a sample of primary care patients (aged 18 to 24 years). The intervention included an initial primary care motivational interview to engage the participant, 11 Internet-based modules based on CBT (to counter pessimistic thinking) and IPT (to activate social networks and strengthen relationship skills), and a follow-up motivational interview in primary care to enhance behavior change. Each component of the intervention was rated with regard to dissemination barriers of (1) fidelity, (2) motivation, (3) dose, (4) perceived helpfulness (rated on a Likert scale), and (5) potential costs. The study was conducted from April through June of 2004.

RESULTS

Fidelity checklist and serial reviews were satisfactory (100% core concepts translated into intervention). Key motivations for participation included (1) risk reduction, (2) intervention effectiveness, (3) "resiliency," and (4) altruism. In terms of dose, 13 of 14 participants engaged the Internet-based components, completing a mean of 7.2 modules (SD = 3.9). The 2 primary care interviews and the self-assessment and resiliency modules received the highest helpfulness ratings. The duration of the 2 motivational interviews was approximately 17-18 minutes, which is similar to a typical primary care visit.

CONCLUSIONS

By using multidisciplinary teams and incorporating the opinions of potential users, complex preventive mental health interventions can be translated into primary care settings with adequate fidelity, motivation, dose, and perceived helpfulness, and at a reasonably low cost.

Meta-review of the effectiveness of computerised CBT in treating depression

BACKGROUND

Several computerised cognitive behaviour therapy (cCBT) packages are now available to treat mild to moderate depression with or without anxiety. These have been usually been reviewed alongside cCBT for a wide range of psychological problems. Here, we single out the results of these reviews for the most common mental disorder, mild to moderate depression. The aim of this paper is to evaluate the quality of existing reviews and to enable reliable comparisons of alternative computer packages for the same patient group.

METHODS

A thorough search and analysis of reviews of efficacy of cCBT published between 1999 and February 2011.

RESULTS

The search yielded twelve systematic reviews from ten studies covering depression. Their methodology is appraised and selected findings are presented here.

CONCLUSIONS

The meta-review supports the efficacy of cCBT for treatment of depression; however there is limited information on different approaches, whose relative cost-effectiveness remains to be demonstrated. Suggestions are made for future studies in the field.

Les études de coûts-efficacité des traitements pharmacologiques et psychologiques des troubles anxieux : une recension des écrits

Cet article porte sur une recension des écrits sur l’évaluation économique des traitements éprouvés cognitivo-comportementaux et pharmacologiques des troubles anxieux. La recherche des articles pertinents s’échelonne de 1980 à 2008, à partir des bases de données électroniques du milieu médical et psychologique. Sept études sont recensées et portent sur le trouble panique, le trouble d’anxiété généralisée, la phobie spécifique et la phobie sociale. Les traitements pharmacologiques et la psychothérapie cognitive-comportementale présentent un rapport coûts-efficacité avantageux, particulièrement lorsque comparés aux soins usuels. Les auteurs concluent que malgré le besoin de renforcer l’état des connaissances sur le rapport coûts-efficacité des interventions, il semble avantageux pour la société d’accroître l’accès aux traitements éprouvés des troubles anxieux.

Evaluation of an online cognitive behavioural therapy program by patients with traumatic brain injury and depression

PRIMARY OBJECTIVE

The most frequently reported psychiatric symptom after traumatic brain injury (TBI) is depression. This study examined whether internet-delivered cognitive behaviour therapy (CBT) could be appropriate and effective for patients with mild or moderate TBI and depression.

METHODS AND PROCEDURES

Patients were recruited for an at-home, 6-week internet-based CBT program (MoodGYM). Participants were assessed during this period by weekly telephone calls and at 12 months post-enrolment. Intervention completion rates, predictors of adherence, user feedback and changes in scores on validated depression scales were assessed.

MAIN OUTCOMES AND RESULTS

Twenty-one patients were recruited: 64% and 43% completed the 6-week intervention and the 12-month follow-up, respectively. Adherence rates were not predicted by demographic or injury characteristics in this small sample. Patients identified reading, memory and comprehension requirements as limitations of the program. Scores on the depression scales were significantly decreased upon completion of the intervention and at the 12-month follow-up.

CONCLUSIONS

The MoodGYM program may be effective for treating symptoms of depression in patients with TBI. While adherence rates were not predicted by age, education level or injury severity, demands upon memory and concentration which may already be compromised in these patients need to be considered.

Design of an internet-based health economic evaluation of a preventive group-intervention for children of parents with mental illness or substance use disorders

Background

Preventive interventions are developed for children of parents with mental and substance use disorders (COPMI), because these children have a higher risk of developing a psychological or behavioral disorder in the future. Mental health and substance use disorders contribute significantly to the global burden of disease. Although the exact number of parents with a mental illness is unclear, the subject of mentally ill parents is gaining attention. Moreover there is a lack of interventions for COPMI-children, as well of (cost-) effectiveness studies evaluating COPMI interventions. Innovative interventions such as e-health provide a new field for exploration. There is no knowledge about the opportunities for using the internet to prevent problems in children at risk. In the current study we will focus on the (cost-) effectiveness of an online health prevention program for COPMI-children.

Methods/Design

We designed a randomized controlled trial to examine the (cost-) effectiveness of the Kopstoring intervention. Kopstoring is an online intervention for COPMI-children to strengthen their coping skills and prevent behavioral and psychological problems. We will compare the Kopstoring intervention with (waiting list) care as usual. This trial will be conducted entirely over the internet. An economic evaluation, from a societal perspective will be conducted, to examine the trial's cost-effectiveness. Power calculations show that 214 participants are needed, aged 16-25. Possible participants will be recruited via media announcements and banners on the internet. After screening and completing informed consent procedures, participants will be randomized. The main outcome is internalizing and externalizing symptoms as measured by the Youth Self Report. For the economic evaluation, healthcare costs and costs outside the healthcare sector will be measured at the same time as the clinical measures, at baseline, 3, 6 and 9 months. An extended measure for the intervention group will be provided at 12 months, to examine the long-term effects. In addition, a process evaluation will be conducted.

Discussion

Recent developments, such as international conferences and policy discussions, show the pressing need to study the (cost-) effectiveness of interventions for vulnerable groups of children. This study will shed light on the (cost-) effectiveness of an online preventive intervention.

Trial registration

NTR1982

Cost-effectiveness analysis of an occupational therapy-led lifestyle approach and routine general practitioner's care for panic disorder

OBJECTIVE

To assess the cost-effectiveness of an occupational therapy-led lifestyle approach to treating panic disorder in primary care compared with routine general practitioner's (GP) care. The burden of mental health disorders is considerable. Cost-effective interventions are necessary to alleviate some of these burdens. Habitual lifestyle behaviours influence mood, although to date mainly single lifestyle factor trials have been conducted to examine the effects on anxiety.

METHODS

An economic evaluation was conducted alongside an unblinded pragmatic randomised controlled trial with assessment at 5 and 10 months. Costs and consequences, as measured by the Beck anxiety inventory (BAI) and quality adjusted life years (QALYs), were compared using incremental cost-effectiveness ratios (ICERs).

RESULTS

The occupational therapy-led lifestyle intervention was more costly than routine GP care at both 5 and 10 months. Significant outcome improvements were evident at 5 months when using the BAI, although these were not maintained at 10 months. Small differences in mean QALYs were found. The estimated ICER was 36 pounds per BAI improvement for 5 months and 39 pounds for 10 months, and 18,905 pounds per QALY gained for 5 months and 8,283 pounds for 10 months.

CONCLUSIONS

If the maximum willingness to pay per additional QALY is 30,000 pounds, then there is an 86% chance that a lifestyle intervention may be considered to be value-for-money over 10 months.

Efficacy of cognitive behavioral therapy training using brief e-mail sessions in the workplace: a controlled clinical trial

In the present study, we conducted a clinical controlled trial to evaluate the effects of cognitive behavioral therapy (CBT) training in improving depression and self-esteem in workers. A total of 261 workers were assigned to either an intervention group (n=137) or a waiting-list group (n=124). The intervention group was offered participation in a group session with CBT specialists and three e-mail sessions with occupational health care staff. Between-group differences in the change in Center for Epidemiologic Studies Depression Scale (CES-D) and Self-Esteem Scale from baseline to three months after the end of training were assessed by analysis of covariance. All subjects in the intervention group completed the group session and 114 (83%) completed the three e-mail sessions. CES-D score decreased by 2.21 points in the intervention group but increased by 0.12 points in the control group, a significant difference of -2.33 points (95% confidence interval: -3.89 to-0.77; p<0.001). The between-group difference in change of self-esteem scores was not significant. Results of the present study suggest that CBT training cooperatively provided by CBT specialists and occupational health care staff using brief e-mail is effective in improving feelings of depression in workers.

Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence

BACKGROUND

Studies of cognitive behavioural therapy delivered by computer (cCBT) show clinical efficacy for treating anxiety and depression, but have not focused on barriers to uptake. Potential barriers include adverse consequences, accessibility and acceptability.

METHOD

An integrated systematic review was conducted of quantitative and qualitative studies and surveys from multiple electronic databases where computers delivered cCBT for anxiety or depression.

RESULTS

Substantial numbers of potential participants are lost prior to trials commencing with little explanation. Among trial participants, drop-outs may be higher in the cCBT groups (odds ratio 2.03, 95% confidence interval 0.81-5.09). Only a median of 56% completed a full course of cCBT and personal circumstance was a more common cause of drop-out than difficulties with the technology or social background. Risk was rarely assessed in the majority of programs. Significant staff time was needed to support clients. Therapists were more negative about cCBT than clients.

CONCLUSIONS

While cCBT is likely to be an effective and acceptable intervention for some people, there are barriers to its uptake that will substantially limit its impact if not addressed. These included investigating the outcome and attitudes of those who do not make it as far as cCBT trials and why so few finish a full course of cCBT.

Erratum

This article has been withdrawn as it was published elsewhere and accidentally duplicated. The original article can be seen here: 10.1108/13619322200800019. When citing the article, please cite: M Ferriter, E Kaltenthaler, G Parry, C Beverley, (2008), “Computerised Cognitive Behaviour Therapy for Phobias and Panic Disorder: A Systematic Review”, Mental Health Review Journal, Vol. 13 Iss: 3, pp. 24 - 31.

Methodological challenges in online trials

Health care and health care services are increasingly being delivered over the Internet. There is a strong argument that interventions delivered online should also be evaluated online to maximize the trial's external validity. Conducting a trial online can help reduce research costs and improve some aspects of internal validity. To date, there are relatively few trials of health interventions that have been conducted entirely online. In this paper we describe the major methodological issues that arise in trials (recruitment, randomization, fidelity of the intervention, retention, and data quality), consider how the online context affects these issues, and use our experience of one online trial evaluating an intervention to help hazardous drinkers drink less (DownYourDrink) to illustrate potential solutions. Further work is needed to develop online trial methodology.

Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes

OBJECTIVE

The authors sought to evaluate 2 approaches with varying time and complexity in engaging adolescents with an Internet-based preventive intervention for depression in primary care. The authors conducted a randomized controlled trial comparing primary care physician motivational interview (MI, 5-10 minutes) + Internet program versus brief advice (BA, 1-2 minutes) + Internet program.

SETTING

Adolescent primary care patients in the United States, aged 14 to 21 years.

PARTICIPANTS

Eighty-four individuals (40% non-white) at increased risk for depressive disorders (subthreshold depressed mood >3-4 weeks) were randomly assigned to either the MI group (n = 43) or the BA group (n = 40).

MAIN OUTCOME MEASURES

Patient Health Questionnaire-Adolescent and Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Both groups substantially engaged the Internet site (MI, 90.7% vs BA 77.5%). For both groups, CES-D-10 scores declined (MI, 24.0 to 17.0, p < .001; BA, 25.2 to 15.5, p < .001). The percentage of those with clinically significant depression symptoms based on CES-D-10 scores declined in both groups from baseline to 12 weeks, (MI, 52% to 12%, p < .001; BA, 50% to 15%, p < .001). The MI group demonstrated declines in self-harm thoughts and hopelessness and was significantly less likely than the BA group to experience a depressive episode (4.65% vs 22.5%, p = .023) or to report hopelessness (MI group of 2% vs 15% for the BA group, p = .044) by 12 weeks.

CONCLUSIONS

An Internet-based prevention program in primary care is associated with declines in depressed mood and the likelihood of having clinical depression symptom levels in both groups. Motivational interviewing in combination with an Internet behavior change program may reduce the likelihood of experiencing a depressive episode and hopelessness.

The acceptability to patients of computerized cognitive behaviour therapy for depression: a systematic review

BACKGROUND

Cognitive behaviour therapy (CBT) is widely used to treat depression. However, CBT is not always available to patients because of a shortage of therapists and long waiting times. Computerized CBT (CCBT) is one of several alternatives currently available to treat patients with depression. Evidence of its clinical effectiveness has led to programs being used increasingly within the UK and elsewhere. However, little information is available regarding the acceptability of CCBT to patients.

METHOD

A systematic review of sources of information on acceptability to patients of CCBT for depression.

RESULTS

Sources of information on acceptability included: recruitment rates, patient drop-outs and patient-completed questionnaires. We identified 16 studies of CCBT for the treatment of depression that provided at least some information on these sources. Limited information was provided on patient take-up rates and recruitment methods. Drop-out rates were comparable to other forms of treatment. Take-up rates, when reported, were much lower. Six of the 16 studies included specific questions on patient acceptability or satisfaction although information was only provided for those who had completed treatment. Several studies have reported positive expectancies and high satisfaction in routine care CCBT services for those completing treatment.

CONCLUSIONS

Trials of CCBT should include more detailed information on patient recruitment methods, drop-out rates and reasons for dropping out. It is important that well-designed surveys and qualitative studies are included alongside trials to determine levels and determinants of patient acceptability.

Computerised cognitive-behavioural therapy for depression: systematic review

BACKGROUND

Computerised cognitive-behavioural therapy (CCBT) is used for treating depression and provides a potentially useful alternative to therapist cognitive-behavioural therapy (CBT).

AIMS

To systematically review the evidence for the effectiveness of CCBT for the treatment of mild to moderate depression.

METHOD

Electronic databases were searched to identify randomised controlled trials. Selected studies were quality assessed and data extracted by two reviewers.

RESULTS

Four studies of three computer software packages met the inclusion criteria. Comparators were treatment as usual, using a depression education website and an attention placebo.

CONCLUSIONS

There is some evidence to support the effectiveness of CCBT for the treatment of depression. However, all studies were associated with considerable drop-out rates and little evidence was presented regarding participants' preferences and the acceptability of the therapy. More research is needed to determine the place of CCBT in the potential range of treatment options offered to individuals with depression.

Development of a psychologically enhanced interactive online intervention for hazardous drinking

Aims: The content of novel interventions is often not well specified. We provide a detailed account of the rationale for and redevelopment of an Internet resource for hazardous drinkers—Down Your Drink (DYD) (www.downyourdrink.org.uk). Development Work: An iterative process blended literature reviews of Internet interventions for health conditions and brief treatments for alcohol problems, feedback from users of the original site and from users panels, and completion of a series of developmental tasks. Intervention: The detailed structure and content of the new version of the website is presented. This permits an appreciation of the intended interaction between the user and the intervention, and emphasizes both the freedom of choice available to the user to access diverse material for personal benefit and the value of a clear organizational structure. Conclusions: Presentation of detailed information on the theoretical underpinning, content and structure of an intervention makes it easier to interpret the results of any evaluation and is likely to be of use to those developing other online interventions for alcohol or other health behaviours.

The effectiveness of self help technologies for emotional problems in adolescents: a systematic review

BACKGROUND

Adolescence is a transition period that involves physiological, psychological, and social changes. Emotional problems such as symptoms of anxiety and depression may develop due to these changes. Although many of these problems may not meet diagnostic thresholds, they may develop into more severe disorders and may impact on functioning. However, there are barriers that may make it difficult for adolescents to receive help from health professionals for such problems, one of which is the limited availability of formal psychological therapy. One way of increasing access to help for such problems is through self help technology (i.e. delivery of psychological help through information technology or paper based formats). Although there is a significant evidence base concerning self help in adults, the evidence base is much weaker in adolescents. This study aims to examine the effectiveness of self help technology for the treatment of emotional problems in adolescents by conducting a systematic review of randomized and quasi-experimental evidence.

METHODS

Five major electronic databases were searched: Medline, PsycInfo, Embase, Cochrane Controlled Trials Register and CINAHL. In addition, nine journals were handsearched and the reference lists of all studies were examined for any additional studies. Fourteen studies were identified. Effect sizes were calculated across 3 outcome measures: attitude towards self (e.g. self esteem); social cognition (e.g. self efficacy); and emotional symptoms (i.e. depression and anxiety symptoms).

RESULTS

Meta analysis showed small, non-significant effect size for attitude towards self (ES = -0.14, 95% CI = -0.72 to 0.43), a medium, non-significant effect size for social cognition (ES = -0.49, 95% CI = -1.23 to 0.25) and a medium, non-significant effect size for emotional symptoms (ES = -0.47, 95% CI = -1.00 to 0.07). However, these findings must be considered preliminary, because of the small number of studies, their heterogeneity, and the relatively poor quality of the studies.

CONCLUSION

At present, the adoption of self help technology for adolescents with emotional problems in routine clinical practice cannot be recommended. There is a need to conduct high quality randomised trials in clearly defined populations to further develop the evidence base before implementation.

Web-based cognitive behavioural therapy (W-CBT) for diabetes patients with co-morbid depression: design of a randomised controlled trial

BACKGROUND

Depression is common among people with diabetes, negatively affecting quality of life, treatment adherence and diabetes outcomes. In routine clinical care, diabetes patients have limited access to mental health services and depression therefore often remains untreated. Web-based therapy could potentially be an effective way to improve the reach of psychological care for diabetes patients, at relatively low costs. This study seeks to test the effectiveness of a web-based self-help depression programme for people with diabetes and co-morbid depression.

METHODS/DESIGN

The effectiveness of a web-based self-help course for adults with diabetes with co-morbid depression will be tested in a randomised trial, using a wait-list controlled design. The intervention consists of an 8-week, moderated self-help course that is tailored to the needs of persons living with diabetes and is offered on an individual basis. Participants receive feedback on their homework assignments by e-mail from their coach. We aim to include 286 patients (143/143), as power analyses showed that this number is needed to detect an effect size of 0.35, with measurements at baseline, directly after completing the web-based intervention and at 1, 3, 4 and 6 months follow-up. Patients in the control condition are placed on a waiting list, and follow the course 12 weeks after randomisation. Primary outcomes are depressive symptoms and diabetes-specific emotional distress. Secondary outcomes are satisfaction with the course, perceived health status, self-care behaviours, glycaemic control, and days in bed/absence from work. Questionnaires are administered via the Internet.

DISCUSSION

The intervention being trialled is expected to help improve mood and reduce diabetes-specific emotional distress in diabetes patients with depression, with subsequent beneficial effects on diabetes self-care and glycaemic outcomes. When proven efficacious, the intervention could be disseminated to reach large groups of patients with diabetes and concurrent depressive symptoms.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24874457.

A cross-sectional comparison study of cognitive and emotional well-being in oral cancer patients

The main aim of this study was to establish whether oral cancer patients were at risk of long-term problems with adaptation, whilst investigating contributory factors using a framework of Subjective Well-Being. Three samples of patients treated for either oral cancer (n=115); throat cancer (n=47), or benign conditions of the salivary gland (n=33) were recruited into a cross-sectional, postal questionnaire study. A gender and age matched healthy normative sample (n=115) was recruited for comparison purposes. Measures included The Satisfaction with Life Scale, the General Health Survey (SF-12), Life Orientation Test and the Hospital Anxiety and Depression Scale. Patients with oral cancer demonstrated similar levels of cognitive and emotional well-being as the other samples. Time since treatment and the majority of clinical and treatment related factors had no effect on cognitive and emotional adaptation in any of the patient samples.