Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Training, supervision, and experience of coaches offering digital guided self-help for mental health concerns

Accessible, low-cost intervention options are necessary to address the rise in mental health problems among college students. Digital guided self-help, or coached, programs have been developed to provide such services, with many commercially available. As such, there are a large and growing number of individuals coaching these programs. However, an unmet need is to evaluate and assess best practices for training and supervising individuals in these positions. To this end, we describe how we recruited, trained, and supervised coaches as part of a large randomized controlled trial using a widely available digital commercial platform. Coaches were trained to provide digital guided self-help for depression, anxiety, and/or eating disorders for college students. Coaches initially attended three live training sessions over 2-3 weeks, viewed multiple training videos, and read a detailed coaching manual developed by our team. Thereafter, they attended weekly supervision. Following their term, coaches completed an exit survey to assess their supervision and training experiences. A total of 37 of 70 (53%) graduate-level student coaches completed the survey. The experience was reported as very positive (95%). In particular, the majority reported feeling well prepared, more confident, and felt they had developed useful skills for their own practice.

Blending Video Therapy and Digital Self-Help for Individuals With Suicidal Ideation: Intervention Design and a Qualitative Study Within the Development Process

BACKGROUND

Digital formats have the potential to enhance accessibility to care for individuals with suicidal ideation. However, digital self-help interventions have faced limitations, including small effect sizes in reducing suicidal ideation, low adherence, and safety concerns.

OBJECTIVE

Therefore, we aimed to develop a remote blended cognitive behavioral therapy intervention that specifically targets suicidal ideation by blending video therapy with web-based self-help modules. The objective of this paper is to describe the collaborative development process and the resulting intervention and treatment rationale.

METHODS

First, we compiled intervention components from established treatment manuals designed for people with suicidal ideation or behavior, resulting in the development of 11 drafts of web-based modules. Second, we conducted a qualitative study, involving 5 licensed psychotherapists and 3 lay counselors specialized in individuals with suicidal ideation who reviewed these module drafts. Data were collected using the think-aloud method and semistructured interviews, and a qualitative content analysis was performed. The 4 a priori main categories of interest were blended care for individuals with suicidal ideation, contents of web-based modules, usability of modules, and layout. Subcategories emerged inductively from the interview transcripts. Finally, informed by previous treatment manuals and qualitative findings, we developed the remote blended treatment program.

RESULTS

The participants suggested that therapists should thoroughly prepare the web-based therapy with patients to tailor the therapy to each individual's needs. Participants emphasized that the web-based modules should explain concepts in a simple manner, convey empathy and validation, and include reminders for the safety plan. In addition, participants highlighted the need for a simple navigation and layout. Taking these recommendations into account, we developed a fully remote blended cognitive behavioral therapy intervention comprising 12 video therapy sessions and up to 31 web-based modules. The treatment involves collaboratively developing a personalized treatment plan to address individual suicidal drivers.

CONCLUSIONS

This remote treatment takes advantage of the high accessibility of digital formats while incorporating full sessions with a therapist. In a subsequent pilot trial, we will seek input from individuals with lived experience and therapists to test the feasibility of the treatment.

Exercise intervention and improvement of negative emotions in children: a meta-analysis

BACKGROUND

Anxiety, depression, and stress are the most common mental health problems in childhood. Exercise interventions in childhood help to promote mental health.

OBJECTIVE

To investigate the relationship between exercise interventions and improvement of negative emotions such as anxiety, depression, and stress in children (5-12 years).

METHODS

Articles were searched in five electronic databases from their inception to January 2023. The meta-analysis was performed using Stata 16.0.

RESULTS

Twenty-three intervention studies included 6830 children. 1) The exercise intervention group was significantly better than the control group in improving negative emotions (Standard Mean Difference SMD=-0.25, 95% Confidence Intervals CI: -0.34 to -0.15, P < 0.01). Exercise intervention improved different kinds of negative emotions: anxiety (SMD=-0.19, 95% CI: -0.33 to -0.06, P < 0.01), depression (SMD=-0.22, 95% CI: -0.43 to -0.01, P < 0.01), and stress (SMD=-0.33, 95% CI: -0.53 to -0.14, P < 0.01); it was most effective at relieving problematic stress. Exercise interventions lasting 20-45 min were most effective in improving children's negative emotions (SMD=-0.38, 95% CI: -0.56 to -0.20, P < 0.01). An exercise intervention period of 10 weeks was more effective in improving children's negative mood (SMD=-0.26, 95% CI: -0.34 to -0.17, P = 0.274).

CONCLUSION

Exercise interventions may improve negative emotions such as anxiety, depression, and stress in children. These findings may have clinical implications for children with negative affect. However, these studies showed a large heterogeneity, and the results should be interpreted with caution. Future studies should report the variability of exercise interventions by gender, age group, and type, intensity, and place of exercise.

Exploring the usability of an internet-based intervention and its providing eHealth platform in an eye-tracking study

The proliferation of online eHealth has made it much easier for users to access healthcare services and interventions from the comfort of their own homes. This study looks at how well one such platform-eSano-performs in terms of user experience when delivering mindfulness interventions. In order to assess usability and user experience, several tools such as eye-tracking technology, think-aloud sessions, a system usability scale questionnaire, an application questionnaire, and post-experiment interviews were employed. Participants were evaluated while they accessed the first module of the mindfulness intervention provided by eSano to measure their interaction with the app, and their level of engagement, and to obtain feedback on both the intervention and its overall usability. The results revealed that although users generally rated their experience with the app positively in terms of overall satisfaction, according to data collected through the system usability scale questionnaire, participants rated the first module of the mindfulness intervention as below average. Additionally, eye-tracking data showed that some users skipped long text blocks in favor of answering questions quickly while others spent more than half their time reading them. Henceforth, recommendations were put forward to improve both the usability and persuasiveness of the app-such as incorporating shorter text blocks and more engaging interactive elements-in order to raise adherence rates. Overall findings from this study provide valuable insights into how users interact with the eSano's participant app which can be used as guidelines for the future development of more effective and user-friendly platforms. Moreover, considering these potential improvements will help foster more positive experiences that promote regular engagement with these types of apps; taking into account emotional states and needs that vary across different age groups and abilities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12652-023-04635-4.

[Video-based psychotherapy: current framework conditions, developments, and recommendations for practical implementation]

Video-based psychotherapy is a digital way to deliver psychotherapeutic treatment when traditional on-site psychotherapy cannot be provided due to structural barriers, such as those related to the COVID-19 pandemic. The use of this digital approach has proven to be both effective and accepted among therapists and patients. Legal frameworks for German therapists and recommendations for practical implementation are summarized in this article.

A systematic quality rating of available mobile health apps for borderline personality disorder

BACKGROUND

Mobile health apps (MHAs) may offer a mean to overcome treatment barriers in Borderline Personality Disorder (BPD) mental health care. However, MHAs for BPD on the market lack transparency and quality assessment.

METHODS

European app stores were systematically searched, and two independent trained reviewers extracted relevant MHAs. Employed methods and privacy and security details documentation of included MHAs were extracted. MHAs were then assessed and rated using the German version of the standardized Mobile Application Rating Scale (MARS-G). Mean values and standard deviations of all subscales (engagement, functionality, aesthetics, information, and therapeutic gain) and correlations with user ratings were calculated.

RESULTS

Of 2977 identified MHAs, 16 were included, showing average quality across the four main subscales (M = 3.25, SD = 0.68). Shortcomings were observed with regard to engagement (M = 2.87, SD = 0.99), potential therapeutic gain (M = 2.67, SD = 0.83), existing evidence base (25.0% of included MHAs were tested empirically), and documented privacy and security details. No significant correlations were found between user ratings and the overall total score of the MARS-G or MARS-G main subscales.

CONCLUSIONS

Available MHAs for BPD vary in quality and evidence on their efficacy, effectiveness, and possible adverse events is scarce. More substantial efforts to ensure the quality of MHAs available for patients and a focus on transparency, particularly regarding privacy and security documentation, are necessary.

Component analysis of a synchronous and asynchronous blended care CBT intervention for symptoms of depression and anxiety: Pragmatic retrospective study

BACKGROUND

Depression and anxiety are leading causes of disability worldwide. Though effective treatments exist, depression and anxiety remain undertreated. Blended care psychotherapy, combining the scalability of online interventions with the personalization and engagement of a live therapist, is a promising approach for increasing access to evidence-based care.

OBJECTIVES

To evaluate the effectiveness and individual contribution of two components - i) digital tools and ii) video-based therapist-led sessions - in a blended care CBT-based intervention under real world conditions.

METHODS

A retrospective cohort design was used to analyze N = 1372 US-based individuals who enrolled in blended care psychotherapy. Of these, at baseline, 761 participants had depression symptoms in the clinical range (based on PHQ-9), and 1254 had anxiety symptoms in the clinical range (based on GAD-7). Participants had access to the program as a mental health benefit offered by their employer. The CBT-based blended care psychotherapy program consisted of regular video sessions with therapists, complemented by digital lessons and digital exercises assigned by the clinician and completed in between sessions. Depression and anxiety levels and clients' treatment engagement were tracked throughout treatment. A 3-level individual growth curve model incorporating time-varying covariates was utilized to examine symptom trajectories of PHQ-9 scores (for those with clinical range of depression at baseline) and GAD-7 scores (for those with clinical range of anxiety at baseline).

RESULTS

On average, individuals exhibited a significant decline in depression and anxiety symptoms during the initial weeks of treatment (P < .001), and a continued decline over subsequent weeks at a slower rate (P < .001). Engaging in a therapy session in a week was associated with lower GAD-7 (b = -0.81) and PHQ-9 (b = -1.01) scores in the same week, as well as lower GAD-7 (b = -0.58) and PHQ-9 (b = -0.58) scores the following week (all P < .01). Similarly, engaging with digital lessons was independently associated with lower GAD-7 (b = -0.19) and PHQ-9 (b = -0.18) scores during the same week, and lower GAD-7 (b = -0.25) and PHQ-9 (b = -0.27) the following week (all P < .01).

CONCLUSIONS

Therapist-led video sessions and digital lessons had separate contributions to improvements in symptoms of depression and anxiety over the course of treatment. Future research should investigate whether clients' characteristics are related to differential effects of therapist-led and digital components of care.

Can the management of depression in type 2 diabetes be democratized?

Both type 2 diabetes and depression are common and are projected to increase. There is increasing evidence for a bidirectional relationship between the two. Diabetes is a risk factor for depression; contrariwise, individuals with depression are at greater risk of developing diabetes. They are a burden for both the individual and the society. Co-existent depression worsens diabetic control because of obesity, insulin resistance and the adverse metabolic effects of anti-diabetes medicines. In addition, compliance to lifestyle measures required for diabetes is also compromised such as following a specific diet, taking proper medications on time, getting metabolic parameters assessed and maintaining a sleep cycle. Depression occurs in many grades; mild depression is more common in diabetes than frank or full-blown depression leading to suicide. Unfortunately, there are not enough trained and accessible mental health professionals such as psychologists or psychiatrists to deal with the increasing burden of depression in diabetes. Therefore, alternate models for management of mild to moderate depression are required. There is evidence that a team-approach by employing health care assistants can lower the risk of cardiac risk factors. INtegrating DEPrEssioN and Diabetes treatmENT study was carried out to determine whether the team-approach using non-health care professionals could be effective in managing mild to moderate depression and to study its effects on metabolic parameters among subjects with type 2 diabetes mellitus. The international study, carried out in four independent centers in India assessed the impact of a trained but not qualified non-psychiatrist in coordinating and forming a fulcrum between the patient, the family and the consultant endocrinologist/diabetologist. The interventions were fine-tuned to be culturally appropriate by qualitative interviews before they began. It was shown that the outcomes of both depression and diabetes could be improved by the employment of a clinical care coordinator. It is possible to scale up the studies to wider geographical areas and health-care organizations.

Unveiling mechanisms of change in digital interventions for depression: Study protocol for a systematic review and individual participant data meta-analysis

INTRODUCTION

The efficacy and effectiveness of digital interventions for depression are both well-established. However, precise effect size estimates for mediators transmitting the effects of digital interventions are not available; and integrative insights on the specific mechanisms of change in internet- and mobile-based interventions (IMIs)-as related to key features like delivery type, accompanying support and theoretical foundation-are largely pending.

OBJECTIVE

We will conduct a systematic review and individual participant data meta-analysis (IPD-MA) evaluating the mediators associated with therapeutic change in various IMIs for depression in adults.

METHODS

We will use three electronic databases (i.e., Embase, Medline/PubMed, PsycINFO) as well as an already established database of IPD to identify relevant published and unpublished studies. We will include (1) randomized controlled trials that examine (2) mediators of (3) guided and unguided (4) IMIs with (5) various theoretical orientations for (6) adults with (7) clinically relevant symptoms of depression (8) compared to an active or passive control condition (9) with depression symptom severity as primary outcome. Study selection, data extraction, as well as quality and risk of bias (RoB) assessment will be done independently by two reviewers. Corresponding authors of eligible primary studies will be invited to share their IPD for this meta-analytic study. In a 1-stage IPD-MA, mediation analyses (e.g., on potential mediators like self-efficacy, emotion regulation or problem solving) will be performed using a multilevel structural equation modeling approach within a random-effects framework. Indirect effects will be estimated, with multiple imputation for missing data; the overall model fit will be evaluated and statistical heterogeneity will be assessed. Furthermore, we will investigate if indirect effects are moderated by different variables on participant- (e.g., age, sex/gender, symptom severity), study- (e.g., quality, studies evaluating the temporal ordering of changes in mediators and outcomes), and intervention-level (e.g., theoretical foundation, delivery type, guidance).

DISCUSSION

This systematic review and IPD-MA will generate comprehensive information on the differential strength of mediators and associated therapeutic processes in digital interventions for depression. The findings might contribute to the empirically-informed advancement of psychotherapeutic interventions, leading to more effective interventions and improved treatment outcomes in digital mental health. Besides, with our novel approach to mediation analyses with IPD-MA, we might also add to a methodological progression of evidence-synthesis in psychotherapy process research.

STUDY REGISTRATION WITH OPEN SCIENCE FRAMEWORK OSF

https://osf.io/md7pq/.

Examining the Impact of Digital Components Across Different Phases of Treatment in a Blended Care Cognitive Behavioral Therapy Intervention for Depression and Anxiety: Pragmatic Retrospective Study

Background

Depression and anxiety incur significant personal and societal costs. Effective psychotherapies exist, such as cognitive behavioral therapy (CBT); however, timely access to quality care is limited by myriad barriers. Blended care therapy models incorporate traditional face-to-face therapy with scalable, digital components of care, expanding the reach of evidence-based care.

Objective

The aim of this study is to determine the effectiveness of a blended care CBT program (BC-CBT) in real-world settings and examine the unique impacts of the (1) digital components of care (video lessons and digital exercises) and (2) phase of treatment (early versus late) in decreasing symptoms of anxiety and depression.

Methods

This retrospective cohort analysis included 3401 US-based individuals enrolled in a BC-CBT program, who presented with clinical levels of depression and/or anxiety. The treatment program consisted of regular therapy sessions augmented by clinician-assigned digital video lessons and exercises. A growth curve model incorporating time-varying covariates examined the relationship between engagement with BCT components (ie, therapy sessions, digital video lessons, and digital exercises) during the early (weeks 0-7) and late (weeks 8-15) phases of treatment, and weekly symptom reports on depression and anxiety measures.

Results

On average, a significant decline in depression and anxiety symptoms was observed during the initial weeks of treatment (P<.001), with a continued, though slower, decline over subsequent weeks (P<.001). Each session completed was associated with significant decreases in anxiety (b=–0.72) and depression (b=–0.83) in the early phase, as well as in the late phase (anxiety, b=–0.47; depression, b=–0.27). Significant decreases in anxiety (b=–0.15) and depression (b=–0.12) were observed for time spent on video lessons (measured in 10-minute intervals) in the early phase of treatment. Engaging with exercises was associated with statistically significant increases in anxiety symptoms (b=0.03) during the early phase of treatment. However, sensitivity analyses examining the effects of exercises in isolation revealed significant decreases in anxiety (b=–0.05) in the early phase, suggesting a potential suppression effect in the larger model.

Conclusions

Using a retrospective cohort design, therapy sessions and digital video lessons were uniquely predictive of improvements in depression and anxiety symptoms, and their effects were modulated based on the phase of treatment (early vs late). Future research should investigate whether other treatment variables, such as therapeutic alliance or familiarity with technology, are related to differential effects on various components of care.

eSano - An eHealth Platform for Internet- and Mobile-based Interventions

The prevention and treatment of mental disorders and chronic somatic diseases is a core challenge for health care systems of the 21th century. Mental- and behavioral health interventions provide the means for lowering the public health burden. However, structural deficits, reluctance to use existing services, perceived stigma and further personal and environmental reasons restrict the uptake of these evidence-based approaches. Internet- and mobile-based interventions (IMIs) might overcome some of the limitations of on-site interventions by providing an anonymous, scalable, time- and location-independent, yet evidence-based approach. In order to implement digital mental and behavioral health concepts across the life-span into practice, a technical solution to support the design, creation, and execution of IMIs is needed. However, there are various conceptual, technical as well as legal challenges to implementing a corresponding software solution in the healthcare domain. Therefore, the work at hand (1) identifies these challenges and derives a number of respective requirements, (2) introduces the eHealth platform eSano, a software project developed by an interdisciplinary team of computer scientists, psychologists, therapists, and other domain experts, with the aim to serve as a flexible basis for mental and behavioral research and health care, and (3) provides technical insights into the developed platform and its approach to address the aforementioned requirements.

Blended Care in In-Patient Acute Psychiatric Care. The Example of a Group Training for Social Competences in Adults-A Pretest-Posttest Feasibility Study

INTRODUCTION

Deficits in social skills can be an important modulating factor in the development and progress of various mental disorders. However, limited resources in inpatient care often impede effective social skills training. This study investigates the feasibility of a blended group training for social skills (SST) in an inpatient psychiatric setting. Methods and Analysis: For this one-group pretest-posttest trial, inpatients with a diagnosed mental disorder were recruited. Participation in the blended SST lasted four weeks and took place within usual inpatient psychiatric care. The blended intervention comprised four face-to-face group sessions and three complementary online modules within four weeks. Assessments took place before (t1) and after (t2) the training. Feasibility outcomes (use, acceptance, satisfaction, implementability into usual psychiatric inpatient care) and effectiveness outcomes regarding social skills were assessed.

RESULTS

N = 15 participants were recruited. Most patients completed all questionnaires (93%) and all modules of the blended SST concept (60%). All participants (100%) would recommend the blended intervention to a friend. Regarding social skills, exploratory analyses revealed a non-significant medium-sized effect (Cohen's d = 0.5 95%CI 0.3 to 1.25, p = 0.08).

DISCUSSION

This trial shows that a blended care SST is feasible for the use in acute psychiatric inpatient care setting. Although the wards were acute, with high turnover and change of inpatients, 60% of participants were treated per protocol over four weeks. Overall, the evidence on blended care concepts in psychiatric care settings is extremely poor to date. Hence, this trial should encourage intensified blended inpatient psychiatric care research.