HealthySMS Text Messaging System Adjunct to Adolescent Group Cognitive Behavioral Therapy in the Context of COVID-19 (Let's Text!): Pilot Feasibility and Acceptability Study

BACKGROUND

The widespread occurrence and devastating impact of adolescent depression warrant health service research focused on feasible and acceptable digital health tools to supplement evidence-based intervention (EBI) efforts, particularly in the context of shelter-in-place guidelines disrupting youth socialization and service use in the wake of the COVID-19 pandemic. Given the promise of SMS text message interventions to enhance EBI engagement, our team developed the HealthySMS system as an adjunct to one of the most empirically supported interventions for adolescent depression: cognitive behavioral therapy (CBT) group services. The system sends daily SMS text messages requesting responses assessing mood, thoughts, and activities; weekly attendance reminder messages; daily tips about adherence (eg, a prompt for activity completion); and personalized responses based on participants' texts.

OBJECTIVE

This study aims to evaluate the feasibility and acceptability of HealthySMS in a real-world setting and explore potential mechanisms of change in EBI engagement, before evaluating the system's impact on adolescents' group CBT engagement and, ultimately, depression outcomes.

METHODS

Over the course of 2020, we invited all 20 adolescents receiving CBT group services for depression at an outpatient psychiatry clinic to enroll in our HealthySMS study; ultimately, 17 (85%) adolescents agreed to participate. We tracked participant initiation and engagement with the HealthySMS system as well as the content of SMS text message responses to HealthySMS. We also invited each participant to engage in a semistructured interview to gather additional qualitative inputs on the system.

RESULTS

All (n=17, 100%) research participants invited agreed to receive HealthySMS messages, and 94% (16/17) of the participants maintained use during the first month without opting out. We uncovered meaningful qualitative themes regarding the feasibility and acceptability of HealthySMS, as well as its potential impact on EBI engagement.

CONCLUSIONS

Taken together, the results of this pilot study suggest that HealthySMS adjunct to adolescent CBT group depression services is feasible and acceptable, as evidenced by high rates of HealthySMS initiation and low rates of dropout, as well as meaningful themes uncovered from participants' qualitative feedback. In addition, the findings provide evidence regarding iterative improvements to the HealthySMS system and research protocol, as well as potential mechanisms of change for enhanced EBI engagement and, ultimately, adolescent depression outcomes, which can be used in future effectiveness research.

Improvements in Adolescents' Disordered Eating Behaviors in a Collaborative Care Digital Mental Health Intervention: Retrospective Observational Study

BACKGROUND

Young people today are exhibiting increasing rates of disordered eating behaviors, as well as eating disorders (EDs), alongside other mental and behavioral problems such as anxiety and depression. However, limited access to mental health care means that EDs, disordered eating behaviors, and comorbid mental health problems are often underdiagnosed and undertreated. Digital mental health interventions (DMHIs) offer accessible and scalable alternatives to traditional treatment modalities, but their effectiveness has not been well established among adolescents with EDs and disordered eating behaviors.

OBJECTIVE

This study uses data from a collaborative care pediatric DMHI to determine whether participation in a DMHI is associated with a reduction in adolescents' disordered eating behaviors.

METHODS

Adolescent members in care with Bend Health Inc completed the SCOFF questionnaire at baseline (before the start of care) and approximately every month during care to assess disordered eating behaviors. They also completed assessments of mental health symptoms at baseline. Member characteristics, mental health symptoms, and disordered eating behaviors of adolescents with elevated SCOFF scores at baseline (before the start of care) were compared to those of adolescents with nonelevated SCOFF scores at baseline. Members participated in web-based coaching or therapy sessions throughout the duration of mental health care.

RESULTS

Compared to adolescents with nonelevated SCOFF scores (n=520), adolescents with elevated SCOFF scores (n=169) were predominantly female and exhibited higher rates of elevated anxiety and depressive symptoms. SCOFF scores decreased over time in care with the DMHI for 61.4% (n=70) of adolescents with elevated SCOFF scores, and each additional month of participation was associated with greater improvements in disordered eating behaviors (F1,233=72.82; P<.001).

CONCLUSIONS

Our findings offer promising preliminary evidence that participation in mental health care with a collaborative care DMHI may be beneficial in the reduction of disordered eating symptoms in adolescents, including those who are experiencing comorbid anxiety and depressive symptoms.

Moderated Online Social Therapy for Carers of Early Psychosis Clients in Real-World Settings: Cluster Randomized Controlled Trial

BACKGROUND

Family carers of youth recovering from early psychosis experience significant stress; however, access to effective family interventions is poor. Digital interventions provide a promising solution.

OBJECTIVE

Our objective was to evaluate across multiple Australian early psychosis services the effectiveness of a novel, web-based early psychosis intervention for carers.

METHODS

In this cluster randomized controlled trial conducted across multiple Australian early psychosis services, our digital moderated online social therapy for carers (Altitudes) plus enhanced family treatment as usual (TAU) was compared with TAU alone on the primary outcome of perceived stress and secondary outcomes including mental health symptoms and family variables at the 6-month follow-up.

RESULTS

Eighty-six caregivers were randomized and data were available for 74 young people in their care. Our primary hypothesis that carers randomized to Altitudes+TAU would report greater improvements in perceived stress at follow-up compared with carers randomized to TAU alone was not supported, with the TAU alone group showing more improvement. For secondary outcomes, the TAU alone group showed improved mindfulness over time. Regardless of group assignment, we observed improvements in satisfaction with life, quality of life, emotional overinvolvement, and burden of care. In contrast, hair cortisol concentration increased. Post hoc analyses revealed more contact with early psychosis services in the intervention group compared to TAU alone and that improvements in perceived stress and social support were associated with use of the intervention in the Altitudes+TAU group. In this study, 80% (12/15) reported a positive experience with Altitudes and 93% (14/15) would recommend it to others.

CONCLUSIONS

Our trial did not show a treatment effect for Altitudes in perceived stress. However, our post hoc analysis indicated that the amount of use of Altitudes related to improvements in stress and social support. Additional design work is indicated to continue users' engagement and to significantly improve outcomes in problem-solving, communication, and self-care.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12617000942358; https://trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12617000942358.

Examining concurrent validity and item selection of the Session Wants and Needs Outcome Measure (SWAN-OM) in a children and young people web-based therapy service

BACKGROUND

Single-session mental health interventions are frequently attended by children and young people (CYP) in both web-based and face-to-face therapy settings. The Session "Wants" and "Needs" Outcome Measure (SWAN-OM) is an instrument developed in a web-based therapy service to overcome the challenges of collecting outcomes and experiences of single-session therapies (SSTs). It provides pre-defined goals for the session, selected by the young person prior to the intervention, on which progress toward achievement is scored at the end of the session.

OBJECTIVE

The objective of this study was to evaluate the instrument's psychometric properties, including concurrent validity against three other frequently used outcome and experience measures, at a web-based and text-based mental health service.

METHODS

The SWAN-OM was administered for a period of 6 months to 1,401 CYP (aged 10-32 years; 79.3% white; 77.59% female) accessing SST on a web-based service. Item correlations with comparator measures and hierarchical logistic regressions to predict item selection were calculated for concurrent validity and psychometric exploration.

RESULTS

The most frequently selected items were "Feel better" (N = 431; 11.61%) and "Find ways I can help myself" (N = 411; 11.07%); unpopular items were "Feel safe in my relationships" (N = 53; 1.43%) and "Learn the steps to achieve something I want" (N = 58; 1.56%). The SWAN-OM was significantly correlated with the Experience of Service Questionnaire, particularly the item "Feel better" [rs₍₁₀₉₎ = 0.48, p < 0.001], the Youth Counseling Impact Scale, particularly the item "Learn the steps to achieve something I want" [rs₍₂₂₎ = 0.76, p < 0.001], and the Positive and Negative Affect Schedule, particularly the items "Learn how to feel better" [rs₍₂₂₎ = 0.72, p < 0.001] and "Explore how I feel" [rs₍₇₀₎ = -0.44, p < 0.001].

CONCLUSION

The SWAN-OM demonstrates good concurrent validity with common measures of outcome and experience. Analysis suggests that lesser-endorsed items may be removed in future iterations of the measure to improve functionality. Future research is required to explore SWAN-OM's potential to measure meaningful change in a range of therapeutic settings.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

The Session Wants and Need Outcome Measure: The Development of a Brief Outcome Measure for Single-Sessions of Web-Based Support

Single-session, brief interventions in therapy for young people make up a large proportion of service provision, including in digital mental health settings. Current nomothetic mental health measures are not specifically designed to capture the benefit or ‘change’ directly related to these brief interventions. As a consequence, we set out to design an outcome measure to concretely demonstrate the value of single-session interventions. The Session Wants and Needs Outcome Measure (SWAN-OM) aims to capture in-session goals and focuses on being user-centric, elements critical to the success of single-session and brief interventions which typically are asset-based and solution-focused. We describe the 4-stage process that was followed to develop this measure: (I) classical item generation and development, (II) content and (III) face validity pilot testing, and (IV) a user-experience approach with young people using framework analysis. This final stage was critical to ensure the integration of this outcome tool into a web-based digital therapy setting, a context which adds another layer of design complexity to item and measure development. This iterative methodology was used to overcome the challenges encountered and to place the needs of the young people and service practitioners at the centre of the design process, thus ensuring measure usability. To end, we highlight the main lessons learnt from engaging in this design process. Specifically, the needs of a measure for single-session interventions are considered, before outlining the learning associated with integrating the measure into a digital mental health platform. Both of these areas are emerging fields and, as such, this study contributes to our understanding of how an idiographic patient outcome theory driven measure can be created for use in a web-based digital mental health therapy service.

Therapist behaviours in a web-based mindfulness-based cognitive therapy (eMBCT) for chronic cancer-related fatigue - Analyses of e-mail correspondence

Web-based mindfulness-based cognitive therapy (eMBCT) has been found effective in decreasing fatigue severity in patients suffering from Chronic Cancer-Related Fatigue (CCRF). In web-based therapy, guidance from a therapist positively affects treatment outcome. So far, less is known about what kind of therapist behaviours contribute to treatment outcome. The present study aimed at 1) identifying therapist behaviours during eMBCT and 2) exploring whether these behaviours were correlated to a decrease in fatigue severity among patients. Qualitative content analyses were performed on 537 feedback e-mails from five therapists sent to 31 patients within a secured portal. Through content analyses, nine therapist behaviours were identified: emphatic utterances, probing self-reflection, informing, psychoeducation, task prompting, paraphrasing, task reinforcement, providing group context and alliance bolstering. Among these behaviours task prompting (19%), paraphrasing (16%) and task reinforcement (15%) were the most common. Linear regression analyses showed a significant association between informing and task prompting on the one hand and a decrease in fatigue severity on the other. Multivariate analysis indicated that informing and task prompting jointly explain the decrease in fatigue. These findings underline the importance for therapists to provide patients with sufficient information and to encourage them to do the exercises.

Tic Treatment Goes Tech: A Review of TicHelper.com

TicHelper.com ("TicHelper") is an interactive online treatment program for youth with chronic tic disorders (CTDs) or Tourette Syndrome (TS) and their parents. It is based on Comprehensive Behavioral Intervention for Tics (CBIT), an individual, outpatient therapy protocol shown to effectively reduce tics in randomized controlled trials. The TicHelper website offers a user-friendly dashboard that is effective in making it easy to navigate through different treatment modules. Modules parallel core CBIT procedures and consist of interactive exercises, informational videos, and self-report ratings. TicHelper has some weaknesses (e.g., no outcomes research specific to the program has been published to date); however, its strengths (easily navigable, clear instructions, appropriate content) outweigh its weaknesses, making it a potentially useful dissemination tool to make CBIT more accessible to families and youth with tics.

From Survivor to Thriver: A Pilot Study of an Online Program for Rape Victims

Approximately 15% to 20% of women have been victims of rape and close to a third report current rape-related PTSD or clinically significant depression or anxiety. Unfortunately, very few distressed rape victims seek formal help. This suggests a need to develop alternative ways to assist the many distressed victims of sexual violence. Online treatment programs represent a potentially important alternative strategy for reaching such individuals. The current paper describes a pilot evaluation of an online, therapist-facilitated, self-paced cognitive behavioral program for rape victims. Five college women with current rape-related PTSD were recruited to complete the From Survivor to Thriver (S to T) program in a lab setting over the course of 7 weeks. After completing the program, 4 participants reported clinically significant reductions in PTSD symptoms and no longer met criteria for PTSD. All participants reported clinically significant reductions in vulnerability fears and 4 reported significant reductions in negative trauma-related cognitions. Implications of the results for further development of the S to T program and how clinicians could utilize this program in treating rape-related PTSD are discussed.