Nonuse of Blended Web-Based and Face-To-Face Cognitive Behavioral Therapy for Alcohol Use Disorder: Qualitative Study

BACKGROUND

The use of digital technologies for health care has been the focus of social studies, which have concentrated on the digital divide between individuals who use technology and those who do not-with the latter often being considered as individuals with shortcomings. In Denmark, 91% of the population have computers and 97 out of 100 families have internet access, indicating that lack of access to technology is not the primary reason for nonuse. Although previous studies have primarily focused on participants' perspectives of using internet-based treatment for alcohol use disorder (AUD), no study has investigated individuals' reasons to prefer face-to-face treatment over blended face-to-face and internet-based cognitive behavioral therapy (bCBT) for AUD among treatment-seeking populations.

OBJECTIVE

The aim of this qualitative study was to investigate the nonuse of bCBT among patients with AUD. Specifically, this study aims to explore patients' reasons for choosing not to receive treatment via this format.

METHODS

This study was conducted among Danish patients with AUD who were enrolled in the study "Blending internet treatment into conventional face-to-face treatment for alcohol use disorder (Blend-A)" but had not used bCBT. The participant group consisted of 11 patients with AUD: 3 women and 8 men. The age range of the participants was 29-78 years (mean 59 years). Individual semistructured interviews were conducted using cell phones to gather participants' reasons for not choosing bCBT. The interviews were recorded, transcribed, and analyzed using thematic analysis. Five authors performed the analysis in 3 steps: (1) two authors read the transcripts and coded themes from their immediate impression of the material, (2) one author provided feedback, which was used to group overlapping themes together or create new themes that better reflected the content, and (3) the remaining two authors provided feedback on the analysis to improve its structure, readability, and relevance to the research aim.

RESULTS

We found that the participants had various reasons for choosing face-to-face treatment over bCBT; these reasons were more related to personal matters and lesser to digital health literacy. We identified 4 themes related to personal matters for choosing face-to-face treatment over bCBT: (1) patients' need for attending sessions in person, (2) preference for verbal communication, (3) desire for immediate feedback, and (4) feeling more empowered and motivated with face-to-face sessions.

CONCLUSIONS

This study provides valuable insight into participants' perspectives on blended therapy for AUD and highlights the importance of considering personal factors when designing digital health interventions. Our study indicates that most of the participants choose not to use bCBT for AUD because they perceive such treatment formats as impersonal. Instead, they prefer direct communication with the therapist, including the ability to express and comprehend facial expressions and body language.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-021-03122-4.

Correction: Psychiatric Treatment Conducted via Telemedicine Versus In-Person Modality in Posttraumatic Stress Disorder, Mood Disorders, and Anxiety Disorders: Systematic Review and Meta-Analysis

[This corrects the article DOI: 10.2196/44790.].

Implementing a revised online screening tool in a routine care online clinic treating anxiety and depression

Introduction

The ItFits implementation toolkit was developed as part of the ImpleMentAll EU Project, to help guide implementation processes. The ItFits toolkit was tested in the online clinic, Internetpsykiatrien, in the Region of Southern Denmark, where it was employed to optimize screening and intake procedures. We hypothesized that a larger proportion of assessed patients would be referred to treatment. Further, we hypothesized the completion rate and effectiveness would increase, as a result of including a more relevant sample.

Method

Using the ItFits-toolkit, Internetpsykiatrien developed a revised online screening tool. Data on patient flow and symptom questionnaires was extracted from Internetpsykiatrien six months prior to- and six months after implementation of the revised online screening tool.

Results

A total of 1,830 applicants self-referred for treatment during the study period. A significantly lower proportion of patients were referred to treatment after implementation of the revised screening tool (pre-implementation, n = 1,009; post-implementation, n = 821; odds ratio 0.67, 95% CI: 0.51; 0.87). The number of patients that completed treatment increased significantly (pre-implementation: 136/275 [49.45%], post-implementation, n = 102/162 [62.96%]; odds ratio 1.79, 95% CI 1.20; 2.70). The treatment effect was unchanged (B = 0.01, p = .996). Worth noting, the number of patients that canceled their appointment for the video assessment interview decreased drastically.

Conclusion

By using the ItFits toolkit for a focused and structured implementation effort, the clinic was able to improve the completion rate, which is an important effect in iCBT. However, contrary to our hypotheses, we did not find an increase in clinical effect, nor a larger ratio being referred to treatment after assessment. The decreased number of referrals for treatment could be a result of increased awareness of inclusion criteria among the clinicians.

Psychiatric Treatment Conducted via Telemedicine Versus In-Person Modality in Posttraumatic Stress Disorder, Mood Disorders, and Anxiety Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Telemedicine has played a vital role in providing psychiatric treatment to patients during the rapid transition of services during the COVID-19 pandemic. Furthermore, the use of telemedicine is expected to expand within the psychiatric field. The efficacy of telemedicine is well described in scientific literature. However, there is a need for a comprehensive quantitative review that analyzes and considers the different clinical outcomes and psychiatric diagnoses.

OBJECTIVE

This paper aimed to assess whether individual psychiatric outpatient treatment for posttraumatic stress disorder, mood disorders, and anxiety disorders in adults using telemedicine is equivalent to in-person treatment.

METHODS

A systematic search of randomized controlled trials was conducted using recognized databases for this review. Overall, 4 outcomes were assessed: treatment efficacy, levels of patient satisfaction, working alliance, and attrition rate. The inverse-variance method was used to summarize the effect size for each outcome.

RESULTS

A total of 7414 records were identified, and 20 trials were included in the systematic review and meta-analysis. The trials included posttraumatic stress disorder (9 trials), depressive disorder (6 trials), a mix of different disorders (4 trials), and general anxiety disorder (1 trial). Overall, the analyses yielded evidence that telemedicine is comparable with in-person treatment regarding treatment efficacy (standardized mean difference -0.01, 95% CI -0.12 to 0.09; P=.84; I2=19%, 17 trials, n=1814), patient satisfaction mean difference (-0.66, 95% CI -1.60 to 0.28; P=.17; I2=44%, 6 trials, n=591), and attrition rates (risk ratio 1.07, 95% CI 0.94-1.21; P=.32; I2=0%, 20 trials, n=2804). The results also indicated that the working alliance between telemedicine and in-person modalities was comparable, but the heterogeneity was substantial to considerable (mean difference 0.95, 95% CI -0.47 to 2.38; P=.19; I2=75%, 6 trials, n=539).

CONCLUSIONS

This meta-analysis provided new knowledge on individual telemedicine interventions that were considered equivalent to in-person treatment regarding efficacy, patient satisfaction, working alliance, and attrition rates across diagnoses. The certainty of the evidence regarding efficacy was rated as moderate. Furthermore, high-quality randomized controlled trials are needed to strengthen the evidence base for treatment provided via telemedicine in psychiatry, particularly for personality disorders and a range of anxiety disorders where there is a lack of studies. Individual patient data meta-analysis is suggested for future studies to personalize telemedicine.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021256357; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256357.

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary.

OBJECTIVE

This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia.

METHODS

A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit.

RESULTS

In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it.

CONCLUSIONS

The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04686-4.

Therapist perceptions of the implementation of a new screening procedure using the ItFits-toolkit in an iCBT routine care clinic: A mixed-methods study using the consolidated framework for implementation research

Introduction

This study investigates the implementation of a new, more automated screening procedure using the ItFits-toolkit in the online clinic, Internet Psychiatry (iPsych) (www.internetpsykiatrien.dk), delivering guided iCBT for mild to moderate anxiety and depressive disorders. The study focuses on how the therapists experienced the process.

Methods

Qualitative data were collected from semi-structured individual interviews with seven therapists from iPsych. The interviews were conducted using an interview guide with questions based on the Consolidated Framework for Implementation Research (CFIR). Quantitative data on the perceived level of normalization were collected from iPsych therapists, administrative staff, and off-site professionals in contact with the target demographic at 10-time points throughout the implementation.

Results

The therapists experienced an improvement in the intake procedure. They reported having more relevant information about the patients to be used during the assessment and the treatment; they liked the new design better; there was a better alignment of expectations between patients and therapists; the patient group was generally a better fit for treatment after implementation; and more of the assessed patients were included in the program. The quantitative data support the interview data and describe a process of normalization that increases over time.

Discussion

The ItFits-toolkit appears to have been an effective mediator of the implementation process. The therapists were aided in the process of change, resulting in an enhanced ability to target the patients who can benefit from the treatment program, less expenditure of time on the wrong population, and more satisfied therapists.

Behind the athletic body: a clinical interview study of identification of eating disorder symptoms and diagnoses in elite athletes

Eating disorders are more prevalent in athletes than in the general population and may have severe consequences for sports performance and health. Identifying symptoms can be difficult in athletes because restrictive eating and slim body images are often idealised in a sports setting. The Eating Disorders Examination Questionnaire (EDE-Q) and the SCOFF (Sick, Control, One stone, Fat and Food) questionnaire (SCOFF) are widely used generic instruments to identify symptoms of eating disorders. This study aimed to investigate the instruments’ validity and explore eating disorder symptoms in a sample of athletes.

A sample of 28 athletes (25 females) competing at a national level was interviewed based on the diagnostic criteria for eating disorders. We interviewed 18 athletes with a high score on EDE-Q and 10 with a low score. All interviews were transcribed and analysed from a general inductive approach. We identified 20 athletes with an eating disorder diagnosis, while 8 had no diagnosis. EDE-Q found 90% of the cases, while SCOFF found 94%. EDE-Q found no false-positive cases, while SCOFF found one.

The qualitative results showed that most athletes reported eating concerns, restrictive eating, eating control (counting calories), weight concerns, body dissatisfaction (feeling fat and non-athletic), excessive exercise and health problems (eg, pain, fatigue).

In conclusion, EDE-Q and SCOFF seem valid instruments to screen athletes’ samples but may fail to find 6%–10% cases with eating disorders. Despite athletic bodies and normal body mass index, many athletes report severe eating problems and dissatisfaction with weight and body appearance. Implementation of regular screening may identify these symptoms at an early stage.

Blended Treatment for Alcohol Use Disorder (Blend-A): Explorative Mixed Methods Pilot and Feasibility Study

Background

In Denmark, approximately 150,000 people have alcohol use disorder (AUD). However, only approximately 10% seek AUD treatment, preferably outside conventional health care settings and opening hours. The AUD treatment area experiences low adherence to treatment, as well as high numbers of no-show and premature dropouts.

Objective

The purpose of the Blend-A (Blended Treatment for Alcohol Use Disorder) feasibility and pilot study was to describe the process of translating and adapting the Dutch treatment protocol into Danish and Danish culture with a high amount of user involvement and to report how patients and therapists perceived the adapted version, when trying it out.

Methods

The settings were 3 Danish public municipal outpatient alcohol clinics. Study participants were patients and therapists from the 3 settings. Data consisted of survey data from the System Usability Scale, individual patient interviews, and therapist group interviews. Statistical analyses were conducted using the Stata software and Excel. Qualitative analysis was conducted using a theoretical thematic analysis.

Results

The usability of the treatment platform was rated above average. The patients chose to use the blended treatment format because it ensured anonymity and had a flexible design. Platform use formed the basis of face-to-face sessions. The use of the self-determined platform resulted in a more thorough process. Patient involvement qualified development of a feasible system. Managerial support for time use was essential. Guidance from an experienced peer was useful.

Conclusions

This study indicates that, during the processes of translating, adapting, and implementing blended, guided, internet-based, and face-to-face AUD treatment, it is relevant to focus on patient involvement, managerial support, and guidance from experienced peers. Owing to the discrete and flexible design of the blended offer, it appears that it may reach patient groups who would not otherwise have sought treatment. Therefore, blended treatment may increase access to treatment and contribute to reaching people affected by excessive alcohol use, who would not otherwise have sought treatment. In addition, it seems that the blended offer may enhance the participants’ perceived satisfaction and the effect of the treatment course. Thus, it appears that Blend-A may be able to contribute to existing treatment offers. Such findings highlight the need to determine the actual effect of the Blend-A offer; therefore, an effectiveness study with a controlled design is warranted.

Why treatment is not an option: Treatment naïve individuals, suffering from alcohol use disorders’ narratives about alcohol use and treatment seeking

Aims: To investigate the narratives of in- and outpatients at mental health and somatic hospitals, who suffer from alcohol use disorders (AUD) but have never sought AUD treatment. More specifically, to understand how the individuals view their alcohol use and explore their reasons for not seeking treatment. Methods: Individuals suffering from AUD were recruited at somatic and mental health hospitals. The study was qualitative, based on semi-structured individual interviews. A narrative analysis was performed. A total of six patients participated: three recruited at a mental health hospital, three from a somatic hospital. Results: The individuals described how heavy alcohol use had always characterised their lives; it was part of their surroundings and it added to their quality of life. Two narrative forms within the individuals’ stories were identified, in which treatment was considered either as a positive option for others but not relevant for themselves, or as representing a threat to the individuals’ autonomy. The participants expressed that they did not believe treatment was relevant for them, and if necessary, they preferred to deal with their heavy drinking themselves. Conclusions: Our findings indicate that a broad focus is needed if relatively more individuals suffering from AUD should seek treatment, since they – in spite of clearly suffering from AUD – nevertheless see themselves as heavy drinkers and have not even thought of seeking treatment. Thus, it is not (only) a question about the attractiveness of the treatment offer or due to lack of knowledge about treatment options that patients suffering from AUD do not seek treatment.

Early development of treatment motivation predicts adherence and symptom reduction in an internet-based guided self-help program for binge eating disorder

OBJECTIVE

Lack of motivation is widely acknowledged as a significant factor in treatment discontinuity and poor treatment outcomes in eating disorders. Treatment adherence is lower in internet-based treatment. The current study aimed to assess the relationship between treatment motivation and treatment outcomes in an internet-based therapist-guided intervention for Binge Eating Disorder (BED).

METHOD

Adults (N = 153) with mild to moderate symptoms of BED participated in a 10-session internet-based treatment program. Baseline and between-session scores of "Readiness to change" and "Belief in change" were used to predict treatment completion and eating disorder symptom reduction (EDE-Q Global, BED-Q, and weekly number of binge eating episodes) at post-treatment.

RESULTS

Baseline treatment motivation could not predict treatment completion or symptom reduction. Early measures of treatment motivation (regression slope from sessions 1-5) significantly predicted both treatment completion and post-treatment symptom reduction. "Belief in change" was the strongest predictor for completing treatment (OR = 2.18, 95%-CI: 1.06, 4.46) and reducing symptoms (EDE-Q Global: B = -0.53, p = 0.001; number of weekly binge eating episodes: B = 0.81, p < 0.01).

DISCUSSION

The results indicated that patients entering online treatment for BED feel highly motivated. However, baseline treatment motivation could not significantly predict treatment completion, which contradicts previous research. The significant predictive ability of early measures of treatment motivation supports the clinical relevance of monitoring the development of early changes to tailor and optimize individual patient care. Further research is needed to examine treatment motivation in regard to internet-based treatment for BED with more validated measures.

An analysis of patient motivation for seeking online treatment for binge eating disorder-A mixed methods study combining systematic text condensation with sentiment analysis

OBJECTIVE

Online treatment for binge eating disorder (BED) is an easily available option for treatment compared to most standard treatment procedures. However, little is known about how motivation types characterize this population and how these impact treatment adherence and effect in an online setting. Therefore, we aimed to investigate a sample of written motivation statements from BED patients, to learn more about how treatment and online treatment in particular, presents in this population.

METHODS

Using self-determination theory in a mixed methods context, we investigated which types of motivation were prevalent in our sample, how this was connected with patient sentiment, and how these constructs influence treatment and adherence.

RESULTS

Contrary to what most current literature suggests, we found that in our sample (n = 148), motivation type was not connected with treatment outcome. We did find a strong association between sentiment scores and motivation types, indicating the model is apt at detecting effects. We found that when comparing an adult and young adult population, they did not differ in motivation type and the treatment was equally effective in young adults and adults. In the sentiment scores there was a difference between sentiment score and adherence in the young adult group, as the more positive the young adults were, the less likely they were to complete the program.

DISCUSSION

Because motivation type does not influence online treatment to the same degree as it would in face-to-face treatment it indicates that the typical barriers to treatment may be less crucial in an online setting. This should be considered during intake; as less motivated patients may be able to adhere better to online treatment, because the latter imposes fewer barriers of the kind that only strong motivation can overcome. The fact that motivation type and sentiment score of the written texts are strongly associated, indicate a potential for automated models to detect motivation based on sentiment.

Effectiveness of internet-based cognitive behavioural therapy for binge eating disorder

Introduction

Binge eating disorder (BED) is the most prevalent specific eating disorder. It is characterized by recurrent episodes of binge eating and is associated with feelings of shame and a lack of control. Internet-based treatments are gaining increasing attention as a way to reach more patients with evidence based treatments In 2020 we conducted a preliminary analysis on the effectiveness of an internet-based cognitive behavioural therapy treatment project (Jensen ES, Linnet, J, Holmberg TT, Tarp K, Nielsen JH, Lichtenstein MB. Effectiveness of internet-based guided self-help for binge-eating disorder and characteristics of completers versus noncompleters. Int J Eat Disord. 2020;1-6. https://doi.org/10.1002/eat.23384).

Objectives

This study aims to update the analyses on treatment effect with the patients who have completed treatment in the year following the last data extraction.

Methods

The iBED treatment project is a 10-session psychologist guided internet-based self-help program based on cognitive behavioural therapy. When applying for treatment and upon completion patients respond to a survey containing, among other scales, the eating disorder examination-questionnaire (EDE-Q), binge eating disorder-questionnaire (BED-Q) and various sociodemographic questions. Data will be extracted from the treatment project in anonymized form for analyses.

Results

The preliminary analyses were conducted on 36 completers. These showed large standardized effect sizes on both the EDE-Q subscales (Cohens d ranging from .88-1.65) and on the BED-Q (d = 1.38). The updated effectiveness analyses will be presented at the conference. We expect approximately 70-80 patients to have completed treatment at this time.

Conclusions

Results will be discussed and presented at the conference.

Patient motivations for seeking online therapy for binge eating disorder

Introduction

Binge Eating Disorder (BED) is characterized by repeatedly losing control over eating behavior and consuming large amounts of food within a short period of time. In later years, a growing body of evidence for effectiveness of internet-based Cognitive Behavioral Therapy (iCBT) as treatment for BED has emerged. Regarding the ability to complete a self-help program on the internet, internal self-regulation can be viewed as important.

Objectives

To qualitatively explore patient motivations for seeking therapy for BED according to intrinsic and extrinsic motivation as well as patient reasons for seeking online therapy.

Methods

The research design of this study was qualitatively. The participants were 52 adults suffering from mild to moderate BED. Data consisted of written texts entered by the participants into the online therapy program. The texts addressed the participants’ goals for their treatment course and their motives for seeking online therapy. The texts were analyzed by the means of systematic text condensation.

Results

Pertaining patient motivations for seeking therapy for BED, five main motivations that reached a saturated level in the sample were discovered: wish for control; avoidance of guilt/shame; desire for tools/insights; weight loss; and psychological stress. Participants ranged from one motivational factor to four, no participant had all the motivational factors. Regarding patient reasons for seeking online therapy, the following themes including sub themes were found: online treatment, treatment at home, and flexible treatment.

Conclusions

The results indicate that online therapy for BED may be able to breach some of the barriers there are towards treatment seeking.

Monitowapplication – an investigation of the usability during the first 18 months of commissioning in practice

Introduction

In cognitive behavioral treatment of anxiety disorders, registration of emotions and behavior is an important part of the intervention. Normally, paper and pencil is used but registrations on a mobile application such as MONARCA may be a useful alternative.

Objectives

This study investigates the usability of MONARCA during the first 18 months of commissioning in practice.

Methods

To explore the usability, semi-structured interviews were conducted with seven patients and three therapists, combined with data from a survey questionnaire where 10 patients and 12 therapists rated the usability of the app on the System Usability Scale. Participants were recruited from an outpatient clinic for affective disorders in The Mental Health Services in the Region of Southern Denmark.

Results

Technical performance, time allocation, therapist effort, commitment, enthusiasm, and increased knowledge are imperative factors. Therapists and patients found that the benefits of registering emotions and behaviors on a mobile application were that it was easy for patients to remember to register daily, it was easy to gain an overview over symptom progress, and access to the registrations improved therapist’s ability to prepare sessions.

Conclusions

Overall, the results from the interviews and survey indicated that both patients and therapists found MONARCA useful, but several improvement opportunities regarding application features and use in the treatment course were found.

Disclosure

No significant relationships.

BLEND-A: blending internet treatment into conventional face-to-face treatment for alcohol use disorder - a study protocol

BACKGROUND

A major challenge to psychological treatment for alcohol use disorder (AUD) is patient non-compliance. A promising new treatment approach that is hypothesized to increase patient compliance is blended treatment, consisting of face-to-face contact with a therapist combined with modules delivered over the internet within the same protocol. While this treatment concept has been developed and proven effective for a variety of mental disorders, it has not yet been examined for AUD.

AIMS

The study described in this protocol aims to examine and evaluate patient compliance with blended AUD treatment as well as the clinical and cost effectiveness of such treatment compared to face-to-face treatment only.

METHODS

The study design is a pragmatic, stepped-wedge cluster randomized controlled trial. The included outpatient institutions (planned number of patients: n = 1800) will be randomized in clusters to implement either blended AUD treatment or face-to-face treatment only, i.e. treatment as usual (TAU). Both treatment approaches consist of motivational interviewing and cognitive behavioral therapy. Data on sociodemographics, treatment (e.g. intensity, duration), type of treatment conclusion (compliance vs. dropout), alcohol consumption, addiction severity, consequences of drinking, and quality of life, will be collected at treatment entry, at treatment conclusion, and 6 months after treatment conclusion. The primary outcome is compliance at treatment conclusion, and the secondary outcomes include alcohol consumption and quality of life at six-months follow-up. Data will be analyzed with an Intention-to-treat approach by means of generalized linear mixed models with a random effect for cluster and fixed effect for each step. Also, analyses evaluating cost-effectiveness will be conducted.

DISCUSSION

Blended treatment may increase treatment compliance and thus improve treatment outcomes due to increased flexibility of the treatment course. Since this study is conducted within an implementation framework it can easily be scaled up, and when successful, blended treatment has the potential to become an alternative offer in many outpatient clinics nationwide and internationally.

TRIAL REGISTRATION

Clinicaltrials.gov .: NCT04535258 , retrospectively registered 01.09.20.

Effectiveness of internet-based guided self-help for binge-eating disorder and characteristics of completers versus noncompleters

OBJECTIVE

Binge-eating disorder (BED) is characterized by recurrent episodes of binge eating, accompanied by a lack of control and feelings of shame. Online intervention is a promising, accessible treatment approach for BED. In the current study, we compared completers with noncompleters in a 10-session guided internet-based treatment program (iBED) based on cognitive behavioral therapy.

METHODS

Adults (N = 75) with mild to moderate BED participated in iBED with weekly written support from psychologists. Participants were compared on the Eating Disorder Examination Questionnaire (EDE-Q), diagnostic criteria for BED (BED-Q), major depression inventory (MDI), quality of life (EQ-5D-5L), body mass index (BMI) and sociodemographic variables.

RESULTS

Minor differences were observed between completers and noncompleters on depression. No differences were found in BED-symptoms, BMI, and sociodemographic variables. Participants who completed treatment showed large reductions in eating disorder pathology.

DISCUSSION

More research is needed to determine risk factors for attrition or treatment outcome in internet-based interventions for BED. It is suggested that iBED is an efficient intervention for BED. However, more studies of internet-interventions are needed.

Tailored implementation of internet-based cognitive behavioural therapy in the multinational context of the ImpleMentAll project: a study protocol for a stepped wedge cluster randomized trial

BACKGROUND

Internet-based Cognitive Behavioural Therapy (iCBT) is found effective in treating common mental disorders. However, the use of these interventions in routine care is limited. The international ImpleMentAll study is funded by the European Union's Horizon 2020 programme. It is concerned with studying and improving methods for implementing evidence-based iCBT services for common mental disorders in routine mental health care. A digitally accessible implementation toolkit (ItFits-toolkit) will be introduced to mental health care organizations with the aim to facilitate the ongoing implementation of iCBT services within local contexts. This study investigates the effectiveness of the ItFits-toolkit by comparing it to implementation-as-usual activities.

METHODS

A stepped wedge cluster randomized controlled trial (SWT) design will be applied. Over a trial period of 30 months, the ItFits-toolkit will be introduced sequentially in twelve routine mental health care organizations in primary and specialist care across nine countries in Europe and Australia. Repeated measures are applied to assess change over time in the outcome variables. The effectiveness of the ItFits-toolkit will be assessed in terms of the degree of normalization of the use of the iCBT services. Several exploratory outcomes including uptake of the iCBT services will be measured to feed the interpretation of the primary outcome. Data will be collected via a centralized data collection system and analysed using generalized linear mixed modelling. A qualitative process evaluation of routine implementation activities and the use of the ItFits-toolkit will be conducted within this study.

DISCUSSION

The ImpleMentAll study is a large-scale international research project designed to study the effectiveness of tailored implementation. Using a SWT design that allows to examine change over time, this study will investigate the effect of tailored implementation on the normalization of the use of iCBT services and their uptake. It will provide a better understanding of the process and methods of tailoring implementation strategies. If found effective, the ItFits-toolkit will be made accessible for mental health care service providers, to help them overcome their context-specific implementation challenges.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883 . Retrospectively registered on 29 August 2018.

Gender Differences in Alcohol Treatment

AIMS

Alcohol consumption is a threat to health worldwide and leads to substantial expenses for society. Previous studies have found differences between women and men regarding drinking behaviour and concluded that women need a more multipart type of alcohol use disorder (AUD) treatment. This study aims to examine the differences in outcome between women and men who have completed public outpatient alcohol treatment.

METHODS

A total of 3452 patients, who completed AUD treatment from 2006 to 2018, were included in this follow-up study. Data were collected from the Odense Alcohol Treatment Database. Analyses were performed using a χ2 test and multiple logistic regression.

RESULTS

The calculations showed that women in AUD treatment had a better outcome if they had children (AOR 0.46, P ≤ 0.001) or were living with a partner with AUD (AOR 0.25-0.33, P ≤ 0.001). Women had a worse outcome if they had a higher educational level (AOR 1.40-1.69, P ≤ 0.001) or were employed (AOR 1.66-1.78, P ≤ 0.001).

CONCLUSIONS

This study found that women had more problems associated with alcohol consumption than men, both before and after completion of AUD treatment. Women with employment or education had a poorer outcome than their male counterparts, whereas childcare responsibilities or having a partner with AUD provided a better outcome.

Effectiveness of Optional Videoconferencing-Based Treatment of Alcohol Use Disorders: Randomized Controlled Trial

BACKGROUND

Treatment of alcohol use disorders (AUDs) is characterized by an adherence rate below 50%. Clinical research has found that patient adherence enhances treatment effect; hence, health authorities, clinicians, and researchers strive to explore initiatives contributing to patients receiving treatment. Concurrently, videoconferencing-based treatment is gaining ground within other addiction and psychiatric areas.

OBJECTIVE

The aim of this study was to test whether optional videoconferencing increases adherence to and effectiveness of AUD treatment in a randomized controlled trial (RCT). We hypothesized that the intervention would decrease premature dropout (the primary outcome), as well as increase successful treatment termination, treatment duration, and treatment outcome (secondary outcomes).

METHODS

We conducted this study in the public outpatient alcohol clinic in Odense, Denmark, between September 2012 and April 2013. It was an RCT with 2 groups: treatment as usual (TAU) and treatment as usual with add-on intervention (TAU+I). The TAU+I group had the option, from session to session, to choose to receive treatment as usual via videoconferencing. Data consisted of self-reported responses to the European version of the Addiction Severity Index (EuropASI). We collected data at baseline, at follow-up at 3, 6, and 12 months, and at discharge.

RESULTS

Among consecutive patients attending the clinic, 128 met the inclusion criteria, and 71 of them were included at baseline. For the primary outcome, after 180 days, 2 of 32 patients (6%) in the TAU+I group and 12 of 39 patients (31%) in the TAU group had dropped out prematurely. The difference is significant (P=.008). After 365 days, 8 patients (25%) in the TAU+I group and 17 patients (44%) in the TAU group had dropped out prematurely. The difference is significant (P=.02). For the secondary outcomes, significantly more patients in the TAU+I group were still attending treatment after 1 year (P=.03). We found no significant differences between the 2 groups with regard to successful treatment termination and treatment outcome.

CONCLUSIONS

The results indicate that offering patients optional videoconferencing may prevent premature dropouts from treatment and prolong treatment courses. However, the small sample size precludes conclusions regarding the effect of the intervention, which was not detectable in the patients' use of alcohol and severity of problems.

TRIAL REGISTRATION

The Regional Health Research Ethics Committee System in Denmark: S-20110052; https://komite.regionsyddanmark.dk/wm258128 (Archived by WebCite at http://www.webcitation.org/6tTL3CO6u).

Videoconferencing-Based Treatment of Alcohol Use Disorders: Analyses of Nonparticipation

BACKGROUND

We recently conducted a small randomized controlled trial (RCT) aiming to examine the effectiveness of videoconferencing-based treatment of alcohol use disorders in a real-life setting. The patient and participation rates were lower than anticipated.

OBJECTIVE

The objectives of our study were (1) to examine differences between participants and nonparticipants, and (2) to examine the characteristics of nonparticipants and their reported reasons for not participating.

METHODS

First, we analyzed nonparticipation through a comparative analysis of participants and nonparticipants using data from a clinical database, covering all patients starting treatment at the clinic. Second, on the basis of data from an anonymous questionnaire filled out by nonparticipants, we analyzed barriers to participating and the descriptive sociodemographics of nonparticipants who reported technical barriers versus those who did not.

RESULTS

Of 128 consecutive patients starting treatment during the study period, we found no significant differences between participants (n=71) and nonparticipants (n=51) according to sociodemographics, alcohol measures, and composite scores. Of 51 nonparticipants, 43 filled out the questionnaire with reasons for not participating. We derived 2 categories of barriers from the questionnaire: scientific barriers, which were barriers to the scientific study in general (n=6), and technical barriers, which were barriers to using a laptop or videoconferencing specifically (n=27). We found no significant differences in sociodemographics between nonparticipants who reported technical barriers to participating in the study and those who did not note technical barriers. A total of 13 patients elaborated on technical barriers, and 9 patients found videoconferencing impersonal, preferred personal contact, and would rather attend face-to-face treatment at the clinic.

CONCLUSIONS

Patient barriers to participating in the RCT were mainly concerned with the technology. There were no significant differences between participants and nonparticipants, nor between nonparticipants who noted technical barriers to participating and those who did not. If a similar study is to be conducted or the solution is to be upscaled and implemented, attention should be given to the user friendliness of the technical equipment and the recruitment process, preparing the patients by emphasizing the information given to them about the technical equipment and its advantages.