Examining the role of AI technology in online mental healthcare: opportunities, challenges, and implications, a mixed-methods review

Introduction

Online mental healthcare has gained significant attention due to its effectiveness, accessibility, and scalability in the management of mental health symptoms. Despite these advantages over traditional in-person formats, including higher availability and accessibility, issues with low treatment adherence and high dropout rates persist. Artificial intelligence (AI) technologies could help address these issues, through powerful predictive models, language analysis, and intelligent dialogue with users, however the study of these applications remains underexplored. The following mixed methods review aimed to supplement this gap by synthesizing the available evidence on the applications of AI in online mental healthcare.

Method

We searched the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE, and Cochrane. This review included peer-reviewed randomized controlled trials, observational studies, non-randomized experimental studies, and case studies that were selected using the PRISMA guidelines. Data regarding pre and post-intervention outcomes and AI applications were extracted and analyzed. A mixed-methods approach encompassing meta-analysis and network meta-analysis was used to analyze pre and post-intervention outcomes, including main effects, depression, anxiety, and study dropouts. We applied the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the quality of the evidence.

Results

Twenty-nine studies were included revealing a variety of AI applications including triage, psychotherapy delivery, treatment monitoring, therapy engagement support, identification of effective therapy features, and prediction of treatment response, dropout, and adherence. AI-delivered self-guided interventions demonstrated medium to large effects on managing mental health symptoms, with dropout rates comparable to non-AI interventions. The quality of the data was low to very low.

Discussion

The review supported the use of AI in enhancing treatment response, adherence, and improvements in online mental healthcare. Nevertheless, given the low quality of the available evidence, this study highlighted the need for additional robust and high-powered studies in this emerging field.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=443575, identifier CRD42023443575.

Incorporating a Stepped Care Approach Into Internet-Based Cognitive Behavioral Therapy for Depression: Randomized Controlled Trial

BACKGROUND

Depression is a hidden burden, yet it is a leading cause of disability worldwide. Despite the adverse effects of depression, fewer than one-third of patients receive care. Internet-based cognitive behavioral therapy (i-CBT) is an effective treatment for depression, and combining i-CBT with supervised care could make the therapy scalable and effective. A stepped care model is a framework for beginning treatment with an effective and low-intensity intervention while adapting care based on the patient's needs.

OBJECTIVE

This study investigated the efficacy of a stepped care i-CBT model for depression based on changes in self-reported depressive symptoms.

METHODS

In this single-blinded, randomized controlled trial, participants were allocated to either the i-CBT-only group (28/56, 50%) or the i-CBT with stepped care group (28/56, 50%). Both groups received a 13-week i-CBT program tailored for depression. The i-CBT program was provided through a secure, online mental health clinic called the Online Psychotherapy Tool. Participants read through the sessions and completed the assignments related to each session. Participants in the stepped care group received additional interventions from their care provider based on standard questionnaire scores (ie, Patient Health Questionnaire-9 [PHQ-9], Quick Inventory of Depressive Symptomatology [QIDS], and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form) and their assignment responses. From lowest to highest intensity, the additional interventions included SMS text messages, phone calls, video calls, or a video call with a psychiatrist.

RESULTS

For this study, 56 participants were recruited to complete an i-CBT program (n=28, 50%; mean age 37.9; SD 13.08 y; 7/28, 27% were men) or an i-CBT with stepped care program (n=28, 50%; mean age 40.6; SD 14.28 y; 11/28, 42% were men). The results of this study indicate that the i-CBT program was effective in significantly reducing depressive symptoms, as measured by the PHQ-9 (F4,80=9.95; P<.001) and QIDS (F2,28=5.73; P=.008); however, there were no significant differences in the reduction of depressive symptoms between the 2 groups (PHQ-9: F4,80=0.43; P=.78; QIDS: F2,28=3.05; P=.06). The stepped care group was not significantly better in reducing depressive symptoms than the i-CBT group (PHQ-9, P=.79; QIDS, P=.06). Although there were no significant differences observed between the number of participants who completed the program between the groups (χ21=2.6; P=.10), participants in the stepped care group, on average, participated in more sessions than those who prematurely terminated participation in the i-CBT group (t55=-2; P=.03; 95% CI -4.83 to -0.002).

CONCLUSIONS

Implementing a stepped care approach in i-CBT is an effective treatment for depression, and the stepped care model can assist patients to complete more sessions in their treatment.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04747873; https://clinicaltrials.gov/study/NCT04747873.

Efficacy of an Electronic Cognitive Behavioral Therapy Program Delivered via the Online Psychotherapy Tool for Depression and Anxiety Related to the COVID-19 Pandemic: Pre-Post Pilot Study

BACKGROUND

Lockdowns and social distancing resulting from the COVID-19 pandemic have worsened the population's mental health and made it more difficult for individuals to receive care. Electronic cognitive behavioral therapy (e-CBT) is a cost-effective and evidence-based treatment for anxiety and depression and can be accessed remotely.

OBJECTIVE

The objective of the study was to investigate the efficacy of online psychotherapy tailored to depression and anxiety symptoms during the pandemic.

METHODS

The pilot study used a pre-post design to evaluate the efficacy of a 9-week e-CBT program designed for individuals with depression and anxiety affected by the pandemic. Participants were adults (N=59) diagnosed with major depressive disorder and generalized anxiety disorder, whose mental health symptoms initiated or worsened during the COVID-19 pandemic. The online psychotherapy program focused on teaching coping, mindfulness, and problem-solving skills. Symptoms of anxiety and depression, resilience, and quality of life were assessed.

RESULTS

Participants demonstrated significant improvements in symptoms of anxiety (P=.02) and depression (P=.03) after the intervention. Similar trends were observed in the intention-to-treat analysis. No significant differences were observed in resilience and quality-of-life measures. The sample comprised mostly females, making it challenging to discern the benefits of the intervention in males. Although a pre-post design is less rigorous than a controlled trial, this design was selected to observe changes in scores during a critical period.

CONCLUSIONS

e-CBT for COVID-19 is an effective and accessible treatment option. Improvements in clinical symptoms of anxiety and depression can be observed in individuals whose mental health is affected by the COVID-19 pandemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/study/NCT04476667.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24913.

Comparing clinical decision-making of AI technology to a multi-professional care team in an electronic cognitive behavioural therapy program for depression: protocol

Introduction

Depression is a leading cause of disability worldwide, affecting up to 300 million people globally. Despite its high prevalence and debilitating effects, only one-third of patients newly diagnosed with depression initiate treatment. Electronic cognitive behavioural therapy (e-CBT) is an effective treatment for depression and is a feasible solution to make mental health care more accessible. Due to its online format, e-CBT can be combined with variable therapist engagement to address different care needs. Typically, a multi-professional care team determines which combination therapy most benefits the patient. However, this process can add to the costs of these programs. Artificial intelligence (AI) has been proposed to offset these costs.

Methods

This study is a double-blinded randomized controlled trial recruiting individuals experiencing depression. The degree of care intensity a participant will receive will be randomly decided by either: (1) a machine learning algorithm, or (2) an assessment made by a group of healthcare professionals. Subsequently, participants will receive depression-specific e-CBT treatment through the secure online platform. There will be three available intensities of therapist interaction: (1) e-CBT; (2) e-CBT with a 15-20-min phone/video call; and (3) e-CBT with pharmacotherapy. This approach aims to accurately allocate care tailored to each patient's needs, allowing for more efficient use of resources.

Discussion

Artificial intelligence and providing patients with varying intensities of care can increase the efficiency of mental health care services. This study aims to determine a cost-effective method to decrease depressive symptoms and increase treatment adherence to online psychotherapy by allocating the correct intensity of therapist care for individuals diagnosed with depression. This will be done by comparing a decision-making machine learning algorithm to a multi-professional care team. This approach aims to accurately allocate care tailored to each patient's needs, allowing for more efficient use of resources with the convergence of technologies and healthcare.

Ethics

The study received ethics approval and began participant recruitment in December 2022. Participant recruitment has been conducted through targeted advertisements and physician referrals. Complete data collection and analysis are expected to conclude by August 2024.

Clinical trial registration

ClinicalTrials.Gov, identifier NCT04747873.

Comparing the efficacy of electronic cognitive behavioral therapy to medication and combination therapy for generalized anxiety disorder: a quasi-experimental clinical trial

Background

Generalized anxiety disorder (GAD) is a debilitating mental health disorder with first-line treatments include cognitive behavioral therapy (CBT) and pharmacotherapy. CBT is costly, time-consuming, and inaccessible. Electronic delivery (e-CBT) is a promising solution to address these barriers. However, due to the novelty of this intervention, more research testing the e-CBT efficacy independently and in conjunction with other treatments is needed.

Objective

This study investigated the efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD.

Methods

This study employed a quasi-experimental design where patients selected their preferred treatment modality. Patients with GAD were enrolled in either e-CBT, medication, or combination arms. The 12-week e-CBT program was delivered through a digital platform. The medications followed clinical guidelines. The efficacy of each arm was evaluated using questionnaires measuring depression, anxiety, and stress severity, as well as quality of life.

Results

There were no significant differences between arms (N e-CBT = 41; N Medication = 41; N Combination = 33) in the number of weeks completed or baseline scores. All arms showed improvements in anxiety scores after treatment. The medication and combination arms improved depression scores. The e-CBT and Combination arms improved quality of life, and the combination arm improved stress scores. There were no differences between the groups in depression, anxiety, or stress scores post-treatment. However, the combination arm had a significantly larger improvement in quality of life. Gender and treatment arm were not predictors of dropout, whereas younger age was.

Conclusion

Incorporating e-CBT on its own or in combination with pharmaceutical interventions is a viable option for treating GAD. Treating GAD with e-CBT or medication appears to offer significant improvements in symptoms, with no meaningful difference between the two. Combining the treatments also offer significant improvements, while not necessarily superior to either independently. The findings suggest that all options are viable. Taking the patient's preferred treatment route based on their lifestyle, personality, and beliefs into account when deciding on treatment should be a priority for care providers.

Online cognitive behavioral therapy (eCBT) for the management of depression symptoms in unipolar and bipolar spectrum disorders, a systematic review and network meta-analysis

BACKGROUND

Face-to-face cognitive behavioral therapy (CBT) is effective in the management of depression symptoms in unipolar and bipolar spectrum disorders. Though, compared to electronic adaptations of CBT (eCBT), it carries several accessibility limitations. Furthermore, unlike eCBT for depression symptoms (eCBTg), eCBT specific for bipolar depression (eCBT-Bipol) remains largely understudied. Thus, supplementing this gap, this systematic review and network meta-analysis (NMA) synthesized the available literature on eCBT for the treatment of unipolar and bipolar depression symptoms.

METHOD

MEDLINE, CINAHL, PsycINFO, EMBASE, and Cochrane were searched for relevant randomized controlled trials (RCTs) on eCBTg and eCBT-Bipol The review followed PRISMA guidelines and used the Cochrane risk of bias tool and GRADE criteria for quality assessment. Effect sizes were summarized using standardized mean differences (SMDs) and risk ratios (RRs).

RESULTS

eCBT-Bipol was comparable to eCBTg (SMD: 0.05, 95 % CI: -0.18; 0.28) and other psychotherapeutic interventions (SMD: 0.14, 95 % CI: -0.07; 0.35) for the management of mild to moderate depression symptoms. eCBT-Bipol was significantly more effective than attention controls (SMD: 0.35, 95 % CI: 0.11; 0.59), treatment as usual (SMD: 0.55, 95 % CI: 0.21; 0.90) and no intervention controls (SMD: 0.66, 95 % CI: 0.40; 0.93) in mitigating symptoms.

LIMITATIONS

The scarcity of eCBT-Bipol studies impacted the quality of the evidence in terms of risk of bias and imprecision.

CONCLUSIONS

The findings of this systematic review suggest that eCBT-Bipol has comparable effectiveness to eCBTg in managing depressive symptoms of unipolar and bipolar spectrum disorder. Though, they also highlighted the need for more studies on eCBT-Bipol.

Comparing the Efficacy of an Electronically Delivered Cognitive Behavioral Therapy Program to a Mental Health Check-In Program for Generalized Anxiety Disorder: Protocol for a Randomized Trial

BACKGROUND

Generalized anxiety disorder (GAD) is a prevalent anxiety disorder, with cognitive behavioral therapy (CBT) being the gold standard treatment. However, it is inaccessible and costly to many, as the mental health industry is overwhelmed by the demand for treatment. This means effective, accessible, and time-saving strategies must be developed to combat these problems. Web-based interventions for mental health disorders are an innovative and promising way to address these barriers. While electronically delivered CBT (e-CBT) has already proved productive and scalable for treating anxiety, other less resource-intensive interventions can be innovated. Checking up on mental health face-to-face has been shown to provide similar benefits to patients with anxiety disorders previously, but more research is needed to evaluate the efficacy of web-based delivery of this intervention.

OBJECTIVE

This study will compare the efficacy of e-CBT and a web-based mental health check-in program to treat GAD. These programs will both be delivered through a secure, web-based care delivery platform.

METHODS

We will randomly allocate participants (N=100) who are 18 years or older with a confirmed diagnosis of GAD to either an e-CBT program or a mental health check-in program over 12 weeks to address their anxiety symptoms. Participants in the e-CBT arm will complete predesigned modules and homework assignments while receiving personalized feedback and asynchronous interaction with a therapist through the platform. Participants in the mental health check-in arm will be contacted weekly through the web-based platform's written chat feature (messaging system). Therapists will ask the participants a series of predesigned questions that revolve around a different theme each week to prompt conversation. Using clinically validated questionnaires, the efficacy of the e-CBT arm will be compared to the mental health check-in arm. These questionnaires will be completed at baseline, week 6, and week 12.

RESULTS

The study received ethics approval in April 2021, and participant recruitment began in May 2021. Participant recruitment has been conducted through targeted advertisements and physician referrals. Complete data collection and analysis are expected to conclude by August 2023. Linear and binomial regression (continuous and categorical outcomes, respectively) will be conducted.

CONCLUSIONS

To the research team's knowledge, this will be the first study to date comparing the efficacy of e-CBT with a web-based mental health check-in program to treat GAD. The findings from this study can help progress the development of more scalable, accessible, and efficacious mental health treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04754438; https://classic.clinicaltrials.gov/ct2/show/NCT04754438.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48899.

A Biological Approach to Building Resilience and Wellness Capacity Among Police Exposed to Posttraumatic Stress Injuries: Protocol for a Randomized Controlled Trial

BACKGROUND

Law enforcement officers are routinely exposed to hazardous, disturbing events that can impose severe stress and long-term psychological trauma. As a result, police and other public safety personnel (PSP) are at increased risk of developing posttraumatic stress injuries (PTSIs) and disruptions to the autonomic nervous system (ANS). ANS functioning can be objectively and noninvasively measured by heart rate (HR), heart rate variability (HRV), and respiratory sinus arrhythmia (RSA). Traditional interventions aimed at building resilience among PSP have not adequately addressed the physiological ANS dysregulations that lead to mental and physical health conditions, as well as burnout and fatigue following potential psychological trauma.

OBJECTIVE

In this study, we will investigate the efficacy of a web-based Autonomic Modulation Training (AMT) intervention on the following outcomes: (1) reducing self-reported symptoms of PTSI, (2) strengthening ANS physiological resilience and wellness capacity, and (3) exploring how sex and gender are related to baseline differences in psychological and biological PTSI symptoms and response to the AMT intervention.

METHODS

The study is comprised of 2 phases. Phase 1 involves the development of the web-based AMT intervention, which includes 1 session of baseline survey measures, 6 weekly sessions that integrate HRV biofeedback (HRVBF) training with meta-cognitive skill practice, and 1 session of follow-up survey measures. Phase 2 will use a cluster randomized control design to test the effectiveness of AMT on the following prepost outcomes: (1) self-report symptoms of PTSI and other wellness measures; (2) physiological indicators of health and resilience including resting HR, HRV, and RSA; and (3) the influence of sex and gender on other outcomes. Participants will be recruited for an 8-week study across Canada in rolling cohorts.

RESULTS

The study received grant funding in March 2020 and ethics approval in February 2021. Due to delays related to COVID-19, phase 1 was completed in December 2022, and phase 2 pilot testing began in February 2023. Cohorts of 10 participants in the experimental (AMT) and control (prepost assessment only) groups will continue until a total of 250 participants are tested. Data collection from all phases is expected to conclude in December 2025 but may be extended until the intended sample size is reached. Quantitative analyses of psychological and physiological data will be conducted in conjunction with expert coinvestigators.

CONCLUSIONS

There is an urgent need to provide police and PSP with effective training that improves physical and psychological functioning. Given that help-seeking for PTSI is reduced among these occupational groups, AMT is a promising intervention that can be completed in the privacy of one's home. Importantly, AMT is a novel program that uniquely addresses the underlying physiological mechanisms that support resilience and wellness promotion and is tailored to the occupational demands of PSP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05521360; https://clinicaltrials.gov/ct2/show/NCT05521360.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/33492.

Evaluating the efficacy of Web-Based Cognitive Behavioural Therapy for the treatment of patients with Bipolar II Disorder and residual depressive symptoms: Protocol for a randomized controlled trial

BACKGROUND

Bipolar disorder (BD) is a highly prevalent psychiatric condition that can significantly impact every aspect of a person's life if left untreated. A subtype of BD, Bipolar disorder II (BD-II) is characterized by long depressive episodes and residual depression symptoms, with short-lived hypomanic episodes. Medication and psychotherapy, such as cognitive behavioral therapy (CBT), are the main treatment options for BD-II. CBT specific for BD-II involves the recognition of warning signs, potentially triggering stimuli, and the development of coping skills to increase euthymic periods and improve global functioning. However, access to in-person CBT may be limited by several barriers including low availability, high costs and geographical limitations. Thus, online adaptations of CBT (e-CBT) have become a promising solution to address these treatment barriers Nevertheless, e-CBT for the treatment of BD-II remains understudied.

OBJECTIVE

The proposed study aims to establish the first e-CBT program specific for the treatment of BD-II with residual depressive symptoms. The primary objective of this study will be to determine the effect of e-CBT in managing BD symptomatology. The secondary objective will be to assess the effects of this e-CBT program on quality of life, and resilience. The tertiary objective will involve gathering user feedback using a post-treatment survey to support the continuous improvement and optimization of the proposed program.

METHODS

Adult participants (n = 170) with a confirmed diagnosis of BD-II experiencing residual depressive symptoms will be randomly assigned to either the e-CBT plus TAU (n = 85) group or the TAU (n = 85) control group. Participants in the control group will be able to participate in the online program after the first 13 weeks. The e-CBT program will consist of 13 weekly online modules designed following a validated CBT framework. Participants will complete module-related homework and receive asynchronous personalized feedback from a therapist. TAU will consist of standard treatment services conducted outside of the current research study. Depression and manic symptoms quality of life and resiliency will be assessed using clinically validated symptomatology questionnaires at baseline, week 6, and week 13.

RESULTS

The study received ethics approval in March 2020 and participant recruitment is expected to begin in February 2023 through targeted advertisements and physician referrals. Data collection and analysis are expected to conclude by December 2024. Linear and binomial regression (continuous and categorical outcomes respectively) will be conducted along with qualitative interpretive methods.

CONCLUSIONS

The findings will be the first on the effectiveness of delivering e-CBT for patients with BD-II with residual depressive symptoms. This approach can provide an innovative method to address barriers to in-person psychotherapy by increasing accessibility and decreasing costs.

CLINICALTRIAL

clinicaltrials.gov (NCT04664257); clinicaltrials.gov/ct2/show/NCT04664257.

Mental health challenges, treatment experiences, and care needs of post-secondary students: a cross-sectional mixed-methods study

BACKGROUND

Post-secondary students frequently experience high rates of mental health challenges. However, they present meagre rates of treatment-seeking behaviours. This elevated prevalence of mental health problems, particularly after the COVID-19 pandemic, can lead to distress, poor academic performance, and lower job prospects following the completion of education. To address the needs of this population, it is important to understand students' perceptions of mental health and the barriers preventing or limiting their access to care.

METHODS

A broad-scoping online survey was publicly distributed to post-secondary students, collecting demographic, sociocultural, economic, and educational information while assessing various components of mental health.

RESULTS

In total, 448 students across post-secondary institutions in Ontario, Canada, responded to the survey. Over a third (n = 170; 38.6%) of respondents reported a formal mental health diagnosis. Depression and generalized anxiety disorder were the most commonly reported diagnoses. Most respondents felt that post-secondary students did not have good mental health (n = 253; 60.5%) and had inadequate coping strategies (n = 261; 62.4%). The most frequently reported barriers to care were financial (n = 214; 50.5%), long wait times (n = 202; 47.6%), insufficient resources (n = 165; 38.9%), time constraints (n = 148; 34.9%), stigma (n = 133; 31.4%), cultural barriers (n = 108; 25.5%), and past negative experiences with mental health care (n = 86; 20.3%). The majority of students felt their post-secondary institution needed to increase awareness (n = 231; 56.5%) and mental health resources (n = 306; 73.2%). Most viewed in-person therapy and online care with a therapist as more helpful than self-guided online care. However, there was uncertainty about the helpfulness and accessibility of different forms of treatment, including online interventions. The qualitative findings highlighted the need for personal strategies, mental health education and awareness, and institutional support and services.

CONCLUSIONS

Various barriers to care, perceived lack of resources, and low knowledge of available interventions may contribute to compromised mental health in post-secondary students. The survey findings indicate that upstream approaches such as integrating mental health education for students may address the varying needs of this critical population. Therapist-involved online mental health interventions may be a promising solution to address accessibility issues.

User experiences of an online therapist-guided psychotherapy platform, OPTT: A cross-sectional study

Introduction

In the last few years, online psychotherapy programs have burgeoned since they are a more accessible and scalable treatment option compared to in-person therapies. While these online programs are promising, understanding the user experience and perceptions of care is essential for program optimization.

Methods

This study investigated the experiences of end-users who had previously received online psychotherapy through a web-based platform. A 35-item multiple-choice survey was developed by the research team and distributed to past users to capture their perceptions of the program.

Results

The survey yielded 163 responses, with a 90 % completion rate. Participants were predominantly white and female, with an average age of 42 years. While most participants preferred in-person therapy, they also reported the benefits of the online psychotherapy program. Participants had positive perceptions of the platform, the quality and interaction of their therapist, and the homework assignments and skills covered. Lack of motivation to complete weekly homework assignments was cited as a common struggle.

Discussion

The findings support online psychotherapy as a beneficial digital mental health tool and highlight some areas for improvement. Scalability and accessibility are key benefits of the platform. At the same time, improvements in participant engagement, including those from equity-seeking and equity-deserving groups, may enhance the efficacy of the programs offered.

Using electronically delivered therapy and brain imaging to understand OCD pathology: A pilot feasibility study

Background

Obsessive–compulsive disorder (OCD) is a debilitating mental health disorder with current psychotherapeutic treatments, while somewhat effective, yielding low accessibility and scalability. A lack of knowledge regarding the neural pathology of OCD may be hindering the development of innovative treatments. Previous research has observed baseline brain activation patterns in OCD patients, elucidating some understanding of the implications. However, by using neuroimaging to observe the effects of treatment on brain activation, a more complete picture of OCD can be drawn. Currently, the gold standard treatment is cognitive behavioral therapy (CBT). However, CBT is often inaccessible, time-consuming, and costly. Fortunately, it can be effectively delivered electronically (e-CBT).

Objectives

This pilot study implemented an e-CBT program for OCD and observed its effects on cortical activation levels during a symptom provocation task. It was hypothesized that abnormal activations could be attenuated following treatment.

Methods

OCD patients completed a 16-week e-CBT program administered through an online platform, mirroring in-person content. Treatment efficacy was evaluated using behavioral questionnaires and neuroimaging. Activation levels were assessed at the resting state and during the symptom provocation task.

Results

In this pilot, seven participants completed the program, with significant improvements (p &lt; 0.05) observed between baseline and post-treatment for symptom severity and levels of functioning. No statistically significant (p = 0.07) improvement was observed in the quality of life. Participants had mostly positive qualitative feedback, citing accessibility benefits, comprehensive formatting, and relatable content. No significant changes in cortical activation were observed between baseline and post-treatment.

Conclusion

This project sheds light on the application of e-CBT as a tool to evaluate the effects of treatment on cortical activation, setting the stage for a larger-scale study. The program showed great promise in feasibility and effectiveness. While there were no significant findings regarding changes in cortical activation, the trends were in agreeance with previous literature, suggesting future work could provide insight into whether e-CBT offers comparable cortical effects to in-person psychotherapy. Applying a greater knowledge of the neural mechanisms of action in OCD can help develop novel treatment plans in the future.

Developing and Implementing a Web-Based Relapse Prevention Psychotherapy Program for Patients With Alcohol Use Disorder: Protocol for a Randomized Controlled Trial

BACKGROUND

 Alcohol use disorder (AUD) is characterized by problematic alcohol use accompanied by clinically substantial distress. Patients with AUD frequently experience high relapse rates, and only 1 in 5 remain abstinent 12 months post treatment. Traditional face-to-face relapse prevention therapy (RPT) is a form of cognitive behavioral therapy (CBT) that examines one's situational triggers, maladaptive thought processes, self-efficacy, and motivation. However, access to this treatment is frequently limited due to its high cost, long waitlists, and inaccessibility. A web-based adaptation of RPT (e-RPT) could address these limitations by providing a more cost-effective and accessible delivery method for mental health care in this population.

OBJECTIVE

 This study protocol aims to establish the first academic e-RPT program to address AUD in the general population. The primary objective of this study is to compare the efficacy of e-RPT to face-to-face RPT in decreasing relapse rates. The secondary objective is to assess the effects of e-RPT on quality of life, self-efficacy, resilience, and depressive symptomatology. The tertiary objective is to evaluate the cost-effectiveness of e-RPT compared to face-to-face RPT.

METHODS

 Adult participants (n=60) with a confirmed diagnosis of AUD will be randomly assigned to receive 10 sessions of e-RPT or face-to-face RPT. e-RPT will consist of 10 predesigned modules and homework with asynchronous, personalized feedback from a therapist. Face-to-face RPT will comprise 10 one-hour face-to-face sessions with a therapist. The predesigned modules and the face-to-face sessions will present the same content and structure. Self-efficacy, resilience, depressive symptomatology, and alcohol consumption will be measured through various questionnaires at baseline, amid treatment, and at the end of treatment.

RESULTS

 Participant recruitment is expected to begin in October 2022 through targeted advertisements and physician referrals. Completed data collection and analysis are expected to conclude by October 2023. Outcome data will be assessed using linear and binomial regression (for continuous and categorical outcomes, respectively). Qualitative data will be analyzed using thematic analysis methods.

CONCLUSIONS

 This study will be the first to examine the effectiveness of e-RPT compared to face-to-face RPT. It is posited that web-based care can present benefits in terms of accessibility and affordability compared to traditional face-to-face psychotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05579210; https://clinicaltrials.gov/ct2/show/NCT05579210.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44694.

Comparison of online and in-person cognitive behavioral therapy in individuals diagnosed with major depressive disorder: a non-randomized controlled trial

Objective

The increased prevalence of major depressive disorder (MDD) amid the COVID-19 pandemic has resulted in substantial growth in online mental health care delivery. Compared to its in-person counterpart, online cognitive behavioral therapy (e-CBT) is a time-flexible and cost-effective method of improving MDD symptoms. However, how its efficacy compares to in-person CBT is yet to be explored. Therefore, the current study compared the efficacy of a therapist-supported, electronically delivered e-CBT program to in-person therapy in individuals diagnosed with MDD.

Methods

Participants (n = 108) diagnosed with MDD selected either a 12 week in-person CBT or an asynchronous therapist-supported e-CBT program. E-CBT participants (n = 55) completed weekly interactive online modules delivered through a secure cloud-based online platform (Online Psychotherapy Tool; OPTT). These modules were followed by homework in which participants received personalized feedback from a trained therapist. Participants in the in-person CBT group (n = 53) discussed sessions and homework with their therapists during one-hour weekly meetings. Program efficacy was evaluated using clinically validated symptomatology and quality of life questionnaires.

Results

Both treatments yielded significant improvements in depressive symptoms and quality of life from baseline to post-treatment. Participants who opted for in-person therapy presented significantly higher baseline symptomatology scores than the e-CBT group. However, both treatments demonstrated comparable significant improvements in depressive symptoms and quality of life from baseline to post-treatment. e-CBT seems to afford higher participant compliance as dropouts in the e-CBT group completed more sessions on average than those in the in-person CBT group.

Conclusion

The findings support e-CBT with therapist guidance as a suitable option to treat MDD. Future studies should investigate how treatment accessibility is related to program completion rates in the e-CBT vs. in-person group.

Clinical Trial Registration

ClinicalTrials.Gov Protocol Registration and Results System (NCT04478058); clinicaltrials.gov/ct2/show/NCT04478058.

Investigating the effectiveness of electronically delivered cognitive behavioural therapy (e-CBTi) compared to pharmaceutical interventions in treating insomnia: Protocol for a randomized controlled trial

BACKGROUND

Insomnia is one of the most prevalent sleep disorders characterized by an inability to fall or stay asleep. Available treatments include pharmacotherapy and cognitive behavioural therapy for insomnia (CBTi). Although CBTi is the first-line treatment, it has limited availability. Therapist-guided electronic delivery of CBT for insomnia (e-CBTi) offers scalable solutions to enhance access to CBTi. While e-CBTi produces comparable outcomes to in-person CBTi, there is a lack of comparison to active pharmacotherapies. Therefore, direct comparisons between e-CBTi and trazodone, one of the most frequently prescribed medications for insomnia, is essential in establishing the effectiveness of this novel digital therapy in the health care system.

OBJECTIVE

The aim of this study is to compare the effectiveness of a therapist-guided electronically-delivered cognitive behavioural therapy (e-CBTi) program to trazodone in patients with insomnia.

METHODS

Patients (n = 60) will be randomly assigned to two groups: treatment as usual (TAU) + trazodone and TAU + e-CBTi for seven weeks. Each weekly sleep module will be delivered through the Online Psychotherapy Tool (OPTT), a secure, online mental health care delivery platform. Changes in insomnia symptoms will be evaluated throughout the study using clinically validated symptomatology questionnaires, Fitbits, and other behavioural variables.

RESULTS

Participant recruitment began in November 2021. To date, 18 participants have been recruited. Data collection is expected to conclude by December 2022 and analyses are expected to be completed by January 2023.

CONCLUSIONS

This comparative study will improve our understanding of the efficacy of therapist-guided e-CBTi in managing insomnia. These findings can be used to develop more accessible and effective treatment options and influence clinical practices for insomnia to further expand mental health care capacity in this population.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05125146).

817 AVOIDING THAT SINKING FEELING: A QIP TO IMPROVE THE IDENTIFICATION OF POSTURAL HYPOTENSION ON A MEDICINE FOR THE ELDERLY WARD

Background

Postural hypotension contributes significantly to falls in frail older people. The RCP recommend that all inpatients &gt;65 years have a lying and standing blood pressure (L&SBP) performed early. We recognised that there was a need to improve the understanding, measurement and consistency of documentation for L&SBP on our ward, a 20-bedded acute MFE ward with many patients at risk of falls.

Methods

This project incorporates two PDSA cycles with three data collection points. We began with baseline measurements of the proportion of patients with: 1) L&SBP recorded within two working days of arrival 2) BP recorded at 1 and 3 minutes, and 3) documentation of associated symptoms. Patients were excluded where it was not possible or appropriate to perform L&SBP. We then carried out a qualitative questionnaire to understand the barriers for staff performing L&SBPs and potential solutions. Our first intervention was to design and deliver a teaching session to all nurses and health care assistants. After re-audit, we created a poster highlighting guidelines for measuring and documenting L&SBPs, and reinforced the learning at MDMs We reviewed the notes of all eligible patients on the ward before and after each intervention.

Results

Our questionnaire revealed useful insights including time constraints and uncertainty of where to document results—these findings allowed us to develop bespoke training for our team.

Discussion

This project demonstrates that junior doctor-led teaching and working with MDT colleagues improves the identification of postural hypotension on a ward. Reinforcement of learning is important.

Benefits of Digital Mental Health Care Interventions for Correctional Workers and Other Public Safety Personnel: A Narrative Review

Chronic exposure to stressors and potentially psychologically traumatic events contributes to the high prevalence of mental health disorders in correctional workers (CWs) and other public safety personnel (PSP). Digital mental health interventions are an accessible and scalable method of improving and maintaining the mental health of this population. The current review explores the benefits of digital mental health interventions for PSP-with a focus on CWs-and how these innovations can address the limitations in in-person mental health care. A systematic literature search of five databases (Medline, PsycInfo, Embase, CINAHL, Google Scholar) was conducted until March 2022. The search yielded 16 publications that focused on digital mental health interventions or care available to CWs and other PSP. The benefits of digital innovations were summarized into five categories which discussed (1) their ability to enhance accessibility and reduce stigma; (2) the provision of evidence-based and structured psychotherapy programs; (3) variability in the degree of therapist engagement; (4) the integration of proactive interventions; and (5) enhancing engagement by acknowledging unique experiences and interpersonal relationships. Although digital mental health technologies for CWs are still in their infancy, there is strong evidence to support their effectiveness in ameliorating symptoms of mental distress. Future research should consider how ethnicity, gender, culture, sexual orientation, and socioeconomic status can be integrated into these therapies and how the interplay between different stakeholders and organizations can impact the effectiveness of online therapies and programs.

A qualitative exploration of the mental health challenges and therapeutic needs of Canadian correctional workers

PURPOSE

Correctional work is described as a high-stress environment associated with increased prevalence of mental health disorders in employees. Identifying appropriate healthcare services necessitates investigating the mental health challenges and needs of correctional workers (CWs).

METHODS

Individual interviews (n = 9; 5 M and 4 W) and a mixed gender focus group (n = 6; 3 M and 3 W) were conducted to gather a general sense of the mental health landscape. Data were analyzed to develop a targeted and comprehensive question guide for gender-specific focus groups (n = 14 unique participants; 6 M and 8 W).

RESULTS

Eight themes emerged from the gender-specific focus groups. Themes focusing on work culture described the negative repercussions of job stress and the inability to discuss challenges openly due to confidentiality concerns and feelings of seclusion associated with the CW profession. Men were more likely to be subjected to physical violence and women to emotional and sexual harassment from staff and inmates. Themes related to mental health care described the benefits and limitations of the current services and digital mental healthcare. Stigma and accessibility were notable treatment barriers. Lastly, sector-specific therapy was seen as an important component in enhancing engagement and therapist interaction.

CONCLUSION

The study demonstrates the interconnection between work culture and CW mental health that needs to be acknowledged when addressing mental health care.

Depression and anxiety following acute myocardial infarction in women

Cardiovascular disease is the leading global cause of mortality, with ischemic heart disease causing the majority of cardiovascular deaths. Despite this, diagnostic delay commonly occurs in women experiencing acute myocardial infarction (AMI) who have a higher associated in-hospital mortality. Several studies have demonstrated that women are significantly more likely than men to experience depression and anxiety following AMI which is linked with increased morbidity, rehospitalization, and mortality, as well as decreased quality of life. Thus, it is imperative that future work aims to understand the factors that put women at higher risk for depression and anxiety following AMI, informing prevention and intervention. This narrative review will summarize the current literature on the association between AMI and mental health in women, including the impact on morbidity, mortality, and quality of life.

Using Electronically Delivered Therapy and Brain Imaging to Understand OCD Pathophysiology: Pilot Protocol

BACKGROUND

Obsessive-compulsive disorder (OCD) is a debilitating and prevalent anxiety disorder. While the basal ganglia and frontal cortex are the most hypothesized brain regions involved, the exact pathophysiology is unknown. By observing the effects of proven treatments on brain activation levels, the cause of OCD can be better understood. Currently, the gold standard treatment for OCD is cognitive behavioural therapy (CBT) with exposure and response prevention (ERP). However, this is often temporally and geographically inaccessible, time-consuming, and costly. Fortunately, CBT can be effectively delivered using the internet (e-CBT) due to its structured nature thus addressing these barriers.

OBJECTIVE

This study will implement an e-CBT program for OCD and observe its effects on brain activation levels using functional magnetic resonance imaging (fMRI). It is hypothesized that brain activation levels in the basal ganglia and frontal cortex will decrease following treatment.

METHODS

Individuals with OCD will be offered a 16-week e-CBT program with ERP mirroring in-person CBT content that will be administered through a secure online platform. Efficacy of treatment will be evaluated using clinically validated symptomology questionnaires at baseline, week 8, and post-treatment (week 16). Using fMRI at baseline and post-treatment, brain activation levels will be assessed at resting state, and while exposed to anxiety-inducing images (i.e., dirty dishes if cleanliness is an obsession). The effects of treatment on brain activation levels and the correlation between symptom changes and activation levels will be analyzed.

RESULTS

The study received initial ethics approval in December 2020 and participant recruitment began in January 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, there have been 5 participants recruited. Data collection is expected to conclude by January 2022, and data analysis is expected to be completed by February 2022.

CONCLUSIONS

The findings from this study can further our understanding of the causation of OCD, helping to develop more effective treatments for this disorder.

CLINICALTRIAL

ClinicalTrials.gov NCT04630197; clinicaltrials.gov/ct2/show/NCT04630197.

Delivering an Online Cognitive Behavioral Therapy Program to Address Mental Health Challenges Faced by Correctional Workers and Other Public Safety Personnel: Protocol for a Mixed Methods Study

BACKGROUND

Public safety personnel have regular and often intense exposure to potentially traumatic events at work, especially workplace violence in the case of correctional workers. Subsequently, correctional workers are at higher risk of developing mental health problems such as posttraumatic stress disorder. Public safety personnel are up to 4 times more likely to experience suicidal ideation, suicidal attempts, and death by suicide compared to the general population. Despite this high prevalence, help-seeking behaviors from public safety personnel are low due to stigma and irregular work hours limiting access to care. Innovative treatments are needed to address these challenges.

OBJECTIVE

This study will investigate the efficacy of an electronically delivered cognitive behavioral therapy (e-CBT) program tailored to correctional workers' mental health problems.

METHODS

This study is composed of 4 phases. In phase 1, we will interview correctional workers individually and in focus groups to identify personal, social, and cultural factors affecting their mental health and barriers to care. Phase 2 will use the information gathered from the interviews to develop gender- and diagnosis-specific e-CBT modules. These will be presented to a new group of participants who will provide further feedback on their usability and accessibility. In phase 3, we will randomly assign participants to either an e-CBT or treatment as usual arm. The program will be evaluated with validated symptomatology questionnaires and interviews. Phase 4 will use this additional information to fine-tune the e-CBT modules for a larger-scale randomized controlled trial design comparing the e-CBT program to in-person CBT. All e-CBT modules will be delivered through a secure online platform.

RESULTS

The study received ethics approval in December 2020, and participant recruitment began in March 2021. Participant recruitment has been conducted through targeted advertisements and physician referrals. To date, there have been 15 participants recruited for Phase 1, and it is expected to conclude in July 2021, with phase 2 beginning in September 2021. Complete data collection and analysis from all phases are expected to conclude by July 2023. Linear and binomial regression (for continuous and categorical outcomes, respectively) will be conducted along with interpretive qualitative methods.

CONCLUSIONS

If proven efficacious and feasible, this e-CBT program can provide a high-quality and clinically validated resource to address the mental health problems of correctional workers. Additionally, findings can contribute to the development of innovative treatments for other public safety professions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04666974; https://www.clinicaltrials.gov/ct2/show/NCT04666974.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30845.

Combining Ketamine and Internet-Based Cognitive Behavioral Therapy for the Treatment of Posttraumatic Stress Disorder: Protocol for a Randomized Controlled Trial

Background

Over one third of patients with posttraumatic stress disorder (PTSD) do not respond to current interventions. Ketamine presents a potential treatment option; however, its effects are temporary. Administering ketamine alongside psychotherapy is one potential means of prolonging its effects; however, only a few studies have investigated this treatment method to date, and none have tested ketamine with internet-based or electronically delivered cognitive behavioral therapy (e-CBT).

Objective

This open-label randomized controlled trial aims to assess the efficacy of a combined treatment method of subanesthetic intravenous ketamine and e-CBT for treating patients with PTSD.

Methods

In total, 20 patients with refractory PTSD recruited from a community clinic will be randomly assigned to either an experimental group (n=10), receiving a combination of ketamine and therapist-administered e-CBT over 14 weeks, or a waitlist control group (n=10), receiving the experimental treatment after 14 weeks. Both groups will be assessed for the symptoms of PTSD and comorbid disorders before treatment, at two midway points, and at the end of the experiment.

Results

PTSD symptoms of participants in the experimental group are expected to improve significantly more than those of participants in the waitlist control group (P=.05) with a large effect size (η²=0.14).

Conclusions

This is the first study to assess the relationship between e-CBT and ketamine and their combined ability to treat refractory PTSD. If successful, this study will open web-based, asynchronous therapeutic options for patients with PTSD and will provide new insights into the functional role of glutamate in trauma-related disorders as well as in learning, memory, and fear extinction.

Trial Registration

ClinicalTrials.gov NCT04771767; https://clinicaltrials.gov/ct2/show/NCT04771767.

International Registered Report Identifier (IRRID)

PRR1-10.2196/30334

Developing and Implementing a Web-Based Psychotherapy Program to Address Mental Health Challenges Among Patients Receiving Oncologic and Palliative Care: Protocol for an Open-Label Randomized Controlled Trial

Background

The demand for mental health care, particularly for depression and anxiety, is 3-fold greater among patients receiving oncologic and palliative care than for the general population. This population faces unique barriers, making them more susceptible to mental health challenges. Various forms of psychotherapy have been deemed effective in addressing mental health challenges in this population, including supportive psychotherapy, cognitive behavioral therapy, problem-based therapy, and mindfulness; however, their access to traditional face-to-face psychotherapy resources is limited owing to their immunocompromised status, making frequent hospital visits dangerous. Additionally, patients can face hospital fatigue from numerous appointments and investigations or may live in remote areas, which makes commutes both physically and financially challenging. Web-based psychotherapy is a promising solution to address these accessibility barriers. Moreover, web-based psychotherapy has been proven effective in addressing depression and anxiety in other populations and may be implementable among patients receiving oncologic and palliative care.

Objective

The study will investigate the feasibility and effectiveness of web-based psychotherapy among patients receiving oncologic and palliative care, who have comorbid depression or anxiety. We hypothesized that this program will be a viable and efficacious treatment modality compared to current treatment modalities in addressing depression and anxiety symptoms in this population.

Methods

Participants (n=60) with depression or anxiety will be recruited from oncology and palliative care settings in Kingston (Ontario, Canada). Participants will be randomly allocated to receive either 8 weeks of web-based psychotherapy plus treatment as usual (treatment arm) or treatment as usual exclusively (control arm). The web-based psychotherapy program will incorporate cognitive behavioral therapy, mindfulness, and problem-solving skills, and homework assignments with personalized feedback from a therapist. All web-based programs will be delivered through a secure platform specifically designed for web-based psychotherapy delivery. To evaluate treatment efficacy, all participants will complete standardized symptomology questionnaires at baseline, midpoint (week 4), and posttreatment.

Results

The study received ethics approval in February 2021 and began recruiting participants in April 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 11 participants (treatment, n=5; control, n=4; dropout, n=2) have been recruited. Data collection and analysis are expected to conclude by December 2021 and January 2022, respectively. Linear regression (for continuous outcomes) will be conducted with interpretive qualitative methods.

Conclusions

Our findings can be incorporated into clinical policy and help develop more accessible mental health treatment options for patients receiving oncologic and palliative care. Asynchronous and web-based psychotherapy delivery is a more accessible, scalable, and financially feasible treatment that could have major implications on the health care system.

Trial Registration

ClinicalTrials.gov NCT04664270; https://clinicaltrials.gov/ct2/show/NCT04664270

International Registered Report Identifier (IRRID)

DERR1-10.2196/30735

Feasibility and Efficacy of Delivering Cognitive Behavioral Therapy Through an Online Psychotherapy Tool for Depression: Protocol for a Randomized Controlled Trial

BACKGROUND

Major depressive disorder (MDD) is a prevalent and debilitating mental health disorder. Among different therapeutic approaches (eg, medication and psychotherapy), psychotherapy in the form of cognitive behavioral therapy (CBT) is considered the gold standard treatment for MDD. However, although efficacious, CBT is not readily accessible to many patients in need because of hurdles such as stigma, long wait times, high cost, the large time commitment for health care providers, and cultural or geographic barriers. Electronically delivered cognitive behavioral therapy (e-CBT) can effectively address many of these accessibility barriers.

OBJECTIVE

This study aims to investigate the efficacy and feasibility of implementing an e-CBT program compared with in-person treatment for MDD. It is hypothesized that the e-CBT program will offer results comparable with those of the in-person treatment program, regarding symptom reduction and quality of life improvement.

METHODS

This nonrandomized controlled trial intervention will provide e-CBT for MDD through the Online Psychotherapy Tool, a secure, cloud-based, digital mental health platform. Participants (aged 18-65 years) will be offered 12 weekly sessions of an e-CBT program tailored to MDD to address their depressive symptoms. Participants (n=55) will complete predesigned modules and homework assignments while receiving personalized feedback and interacting with a therapist through the platform. Using clinically validated symptomology questionnaires, the efficacy of the e-CBT program will be compared with that of a group (n=55) receiving in-person CBT. Questionnaires will be completed at baseline, at week 6 and week 12, and at a 6-month follow-up. Focus groups will be conducted to investigate personal, cultural, and social factors impacting the accessibility and feasibility of implementing a web-based psychotherapy tool from a patient and care provider perspective. Inclusion criteria include diagnosis of MDD, competence to consent to participate, ability to speak and read English, and consistent and reliable access to the internet. Exclusion criteria include active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation.

RESULTS

Ethics approval was obtained in January 2019, and recruitment of participants began in June 2019. Recruitment has been conducted via social media, web-based communities, and physician referrals. To date, 52 participants have been recruited to the e-CBT group, and 48 patients have been recruited to the in-person CBT group. Data collection is expected to be completed by March 2021, and analyses are expected to be completed by June 2021, as linear regression (for continuous outcomes) and binomial regression analysis (for categorical outcomes) are still being conducted.

CONCLUSIONS

The results of this study can provide valuable information for the development of more accessible and scalable mental health interventions with increased care capacity for MDD, without sacrificing the quality of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04478058; http://clinicaltrials.gov/ct2/show/NCT04478058.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27489.

Determining the Efficacy of Electronic Cognitive Behavioral Therapy for Generalized Anxiety Disorder Compared to Pharmaceutical Interventions: Protocol for a Quasi-Experimental Study

BACKGROUND

Generalized anxiety disorder (GAD) is an extremely prevalent and debilitating mental health disorder. Currently, the gold standard treatment for GAD is cognitive behavioral therapy (CBT) and/or pharmacotherapy. The most common medications used to treat GAD are selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors. While CBT is the gold standard treatment for GAD, it is costly, time-consuming, and often inaccessible. Fortunately, the electronic delivery of CBT (e-CBT) has emerged as a promising solution to address these barriers. e-CBT has shown to offer comparable results to in-person CBT while improving accessibility for patients and time efficiency for clinicians.

OBJECTIVE

This study aims to investigate the treatment efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD.

METHODS

This study will use a quasi-experimental design to allow patients the freedom to choose which treatment modality they would like to receive. Participants with a diagnosis of GAD will be enrolled in 1 of 3 possible treatment arms: (1) e-CBT, (2) medication, or (3) a combination of e-CBT and medication. The e-CBT program will include a 12-week psychotherapy program delivered through the Online Psychotherapy Tool-a secure, cloud-based, digital mental health platform. The treatment efficacy of e-CBT will be compared with that of medication alone and medication in combination with e-CBT.

RESULTS

The study received ethics approval in April 2019 and participant recruitment began in June 2019. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 146 participants (e-CBT: n=53; medication: n=49; combination: n=44) have been recruited. Data collection is expected to conclude by June 2021, and data analysis is expected to be completed by October 2021. Linear regression (for continuous outcomes) and binomial regression (for categorical outcomes) analysis will be conducted using interpretive qualitative methods.

CONCLUSIONS

If either the efficacy of e-CBT is shown to be comparable to that of medication or the effects of both treatments are augmented when used in tandem, these findings could have major implications on the mental health care system. e-CBT is a more accessible and affordable treatment that could increase mental health care capacity 4-fold if proven viable.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04478526; https://clinicaltrials.gov/ct2/show/NCT04478526.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27772.

Effectiveness of Delivering Dialectical Behavioral Therapy Techniques by Email in Patients With Borderline Personality Disorder: Nonrandomized Controlled Trial

BACKGROUND

Borderline personality disorder is a debilitating and prevalent mental health disorder, with often inaccessible treatment options. Electronically delivered dialectical behavioral therapy could be an efficacious and more accessible intervention.

OBJECTIVE

We aimed to evaluate the efficacy of electronic delivery of dialectical behavioral therapy in the treatment of individuals with symptoms of borderline personality disorder.

METHODS

Study participants diagnosed with borderline personality disorder were offered either an email-based or in-person group format dialectical behavioral therapy skill-building program. During each session, participants were provided with both the material and feedback regarding their previous week's homework. Electronically delivered dialectical behavioral therapy protocol and content were designed to mirror in-person content. Participants were assessed using the Self-Assessment Questionnaire (SAQ) and Difficulties in Emotion Regulation Scale (DERS).

RESULTS

There were significant increases in SAQ scores from pre- to posttreatment in the electronic delivery group (F_1,92=69.32, P<.001) and in-person group (F_1,92=60.97, P<.001). There were no significant differences observed between the groups at pre- and posttreatment for SAQ scores (F_1,92=.05, P=.83). There were significant decreases in DERS scores observed between pre- and posttreatment in the electronic delivery group (F_1,91=30.15, P<.001) and the in-person group (F_1,91=58.18, P<.001). There were no significant differences observed between the groups for DERS scores pre- and posttreatment (F_1,91=.24, P=.63). There was no significant difference in treatment efficacy observed between the 2 treatment arms (P<.001).

CONCLUSIONS

Despite the proven efficacy of in-person dialectical behavioral therapy in the treatment of borderline personality disorder, there are barriers to receiving this treatment. With the prevalence of internet access continuing to rise globally, delivering dialectical behavioral therapy with email may provide a more accessible alternative to treatment for individuals with borderline personality disorder without sacrificing the quality of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04493580; https://clinicaltrials.gov/ct2/show/NCT04493580.

Using the Online Psychotherapy Tool to Address Mental Health Problems in the Context of the COVID-19 Pandemic: Protocol for an Electronically Delivered Cognitive Behavioral Therapy Program

Background

The considerable rise of mental health challenges during the COVID-19 pandemic has had detrimental effects on the public health sector and economy. To meet the overwhelming and growing demand for mental health care, innovative approaches must be employed to significantly expand mental health care delivery capacity. Although it is not feasible to increase the number of mental health care providers or hours they work in the short term, improving their time efficiency may be a viable solution. Virtually and digitally delivering psychotherapy, which has been shown to be efficient and clinically effective, might be a good method for addressing this growing demand.

Objective

This research protocol aims to evaluate the feasibility and efficacy of using an online, digital, asynchronous care model to treat mental health issues that are started or aggravated by stressors associated with the COVID-19 pandemic.

Methods

This nonrandomized controlled trial intervention will be delivered through the Online Psychotherapy Tool, a secure, cloud-based, digital mental health platform. Participants will be offered a 9-week electronically delivered cognitive behavioral therapy program that is tailored to address mental health problems in the context of the COVID-19 pandemic. This program will involve weekly self-guided educational material that provides an overview of behavioral skills and weekly homework. Participants (N=80) will receive personalized feedback from and weekly interaction with a therapist throughout the course of the program. The efficacy of the program will be evaluated using clinically validated symptomology questionnaires, which are to be completed by participants at baseline, week 5, and posttreatment. Inclusion criteria includes the capacity to consent; a primary diagnosis of generalized anxiety disorder or major depressive disorder, with symptoms that started or worsened during the COVID-19 pandemic; the ability to speak and read English; and consistent and reliable access to the internet. Exclusion criteria includes active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation.

Results

This study received funding in May 2020. Ethics approval was received in June 2020. The recruitment of participants began in June 2020. Participant recruitment is being conducted via social media, web-based communities, and physician referrals. To date, 58 participants have been recruited (intervention group: n=35; control group: n=23). Data collection is expected to conclude by the end of 2020. Analyses (ie, linear regression analysis for continuous outcomes and binomial regression analysis for categorical outcomes) are expected to be completed by February 2021.

Conclusions

If proven feasible, this care delivery method could increase care capacity by up to fourfold. The findings from this study can potentially influence clinical practices and policies and increase accessibility to care during the COVID-19 pandemic, without sacrificing the quality of care.

Trial Registration

ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/ct2/show/NCT04476667

International Registered Report Identifier (IRRID)

DERR1-10.2196/24913

Online Clinic, a New Method of Delivering Psychotherapy

Introduction

Psychotherapy is one of the most widely investigated and practiced forms of treatment used in the treatment of different mental health problems. However, there are some barriers in delivering this treatment, including long waiting lists, therapist shortage and lack of access to therapists in remote areas. Therefore, using alternative methods to overcome these barriers seems necessary.

Method

The division of psychiatry at Queen's university provides different psychotherapy groups for individuals suffering from different kinds of mental health problem. We gave the participants the opportunity to choose online psychotherapy through an online clinic or the live group sessions. All the patients were assessed by different questionnaires for evaluation of the efficacy of the treatment. The online clinic was designed to facilitate the communication between patients and clinicians and the material was delivered in PowerPoint format through the online platform. All user activities were logged for security purposes.

Results

Statistical analysis showed that this method of delivering psychotherapy significantly reduced patients’ symptoms and also decreased the number of people on the waiting list and increased the amount of compliance in patient's taking part in psychotherapy and number of people who were able to receive psychotherapy.

Conclusion

Despite the proven short and long-term efficacy of psychotherapy, there are some barriers in delivering this treatment. It is an unequivocal public health needs to overcome these barriers through alternative methods of therapy. With Internet use ever rising, developing an online clinic could be a new way in delivering different kinds of psychotherapy.

The effect of vitamin D status on ovarian reserve markers in infertile women: A prospective cross-sectional study

Background

Vitamin D deficiency and infertility are two important health problems in Iran. Some studies suggest that vitamin D may influence Anti-Müllerian hormone (AMH) and antral follicle count (AFC) as an ovarian reserve.

Objective

The present study aimed to investigate the impact of vitamin D on AMH serum concentrations/AFC.

Materials and Methods

Three hundred and five infertile women referred to the IVF Unit of Yas hospital, between July and December 2017, were enrolled in this cross-sectional study. The demographic characteristics of the participants, as well as the serum levels of vitamin D, AMH, and ultrasonic examination of AFC were recorded.

Results

Finally, 287 infertile women were included in the analysis with a mean age of 29.95 ± 4.73 yr (18-45 yr) and a mean Body mass indexof 25.11 ± 4.41 kg/m 2 . The median AMH and vitamin D levels were 3.20 and 22.82 ng/ml, respectively. Considering the cut-off level of 20 ng/ml, 58.7% were vitamin D deficient. Regression analysis showed no association between AMH and vitamin D levels (p = 0.161), even after adjusting for baseline variables (p = 0.182). A total of 120 patients had an AFC < 6 and 164 ≥ 6, which was not statistically different between the groups with normal level or deficient vitamin D (p = 0.133).

Conclusion

The present cross-sectional study showed no significant association between serum levels of vitamin D and AMH or AFC in infertile women, even after adjusting for baseline variables.

An Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth Diagnosed With Major Depressive Disorders: Protocol for a Randomized Controlled Trial

Background

About 70% of all mental health disorders appear before the age of 25 years. When untreated, these disorders can become long-standing and impair multiple life domains. When compared with all Canadian youth (of different ages), individuals aged between 15 and 25 years are significantly more likely to experience mental health disorders, substance dependencies, and risks for suicidal ideation and death by suicide. Progress in the treatment of youth, capitalizing on their online responsivity, can strategically address depressive disorders.

Objective

We will conduct a randomized controlled trial to compare online mindfulness-oriented cognitive behavioral therapy (CBT-M) combined with standard psychiatric care versus psychiatric care alone in youth diagnosed with major depressive disorder. We will enroll 168 subjects in the age range of 18 to 30 years; 50% of subjects will be from First Nations (FN) backgrounds, whereas the other 50% will be from all other ethnic backgrounds. There will be equal stratification into 2 intervention groups (INT¹ and INT²) and 2 wait-list control groups (CTL¹ and CTL²) with 42 subjects per group, resulting in an equal number of INT¹ and CTL¹ of FN background and INT² and CTL² of non-FN background.

Methods

The inclusion criteria are: (1) age 18 to 30 years, FN background or other ethnicity; (2) Beck Depression Inventory (BDI)-II of at least mild severity (BDI-II score ≥14) and no upper limit; (3) Mini-International Neuropsychiatric Interview (MINI)–confirmed psychiatric diagnosis of major depressive disorder; and (4) fluent in English. All patients are diagnosed by a Centre for Addiction and Mental Health psychiatrist, with diagnoses confirmed using the MINI interview. The exclusion criteria are: (1) individuals receiving weekly structured psychotherapy; (2) individuals who meet the Diagnostic and Statistical Manual of Mental Disorders criteria for severe alcohol/substance use disorder in the past 3 months, or who demonstrate clinically significant suicidal ideation defined as imminent intent, or who have attempted suicide in the past 6 months; and (3) individuals with comorbid diagnoses of borderline personality, schizophrenia, bipolar disorder, and/or obsessive compulsive disorder. All subjects are provided standard psychiatric care defined as 1 monthly session that focuses on appropriate medication, with session durations of 15 to 30 min. Experimental subjects receive an additional intervention consisting of the CBT-M online software program (in collaboration with Nex J Health, Inc). Exposure to and interaction with the online workbooks are combined with navigation-coaching delivered by phone and secure text message interactions.

Results

The outcomes selected, combined with measurement blinding, are key features in assessing whether significant benefits regarding depression and anxiety symptoms occur.

Conclusions

If results confirm the hypothesis that youth can be effectively treated with online CBT-M, effective services may be widely delivered with less geographic restriction.

International Registered Report Identifier (IRRID)

PRR1-10.2196/11591

Oxidative stability of UV irradiated and X-rayed soybean oil incorporated with rose oil

The effects of UV radiation and X-ray on the oxidative stability of soybean oil were investigated. Also, rose oil was incorporated into soybean oil and its antioxidant activity was compared with that of α-tocopherol during accelerated storage. Treating the samples with radiation (UV and X-ray) stimulated the oxidation process in soybean oil in comparison with samples that did not receive radiation. X-rayed samples had significantly higher amounts of oxidation products than UV irradiated samples. The X-ray caused more oxidation in the samples due to its higher energy content. Also, the antioxidant activity of rose oil was comparable with that of α-tocopherol.

Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt

OBJECTIVE

To determine the efficacy of two interventions on suicide risk assessment within emergency departments (EDs) on improving the documentation of suicide risk factors by emergency medicine and psychiatric physicians during suicide risk assessment.

METHOD

An educational intervention on suicide was provided to all emergency medicine and psychiatry physicians and was followed by the placement of a suicide risk assessment prompt within local EDs. The medical charts of all ED patients presenting with suicidal ideation or behaviours were reviewed immediately and six months after the interventions and compared to pre-intervention. Differences in the documentation of 40 biopsychosocial suicide risk factors between specialties and after the interventions were determined.

RESULTS

The documentation of 34/40 (p ≤ 0.008) and 33/40 (p ≤ 0.009) suicide risk factors was significantly improved by emergency medicine and psychiatry physicians, respectively, after the interventions and maintained six months later. Immediately and six months after the interventions, the documentation of 8/40 (p ≤ 0.041) and 14/40 (p ≤ 0.048) suicide risk factors, respectively, significantly differed between specialties.

CONCLUSION

This suggests that providing a brief educational intervention on suicide to emergency medicine and psychiatry physicians followed by placing a prompt for important, yet commonly undocumented risk factors within the ED is a low-cost and effective intervention for improving documentation of suicide risk assessments within the ED.

Relationship between Bullying and Suicidal Behaviour in Youth presenting to the Emergency Department

OBJECTIVE

Increasing numbers of adolescents are visiting emergency departments with suicidal ideation. This study examines the relationship between bullying and suicidal ideation in emergency department settings.

METHOD

A chart review was conducted for all patients under 18 years of age presenting with a mental health complaint to the emergency departments at Kingston General or Hotel Dieu Hospitals in Kingston, Canada, between January 2011 and January 2015. Factors such as age, gender, history of abuse, history of bullying, type and time of bullying, and diagnoses were documented.

RESULTS

77% of the adolescents had experienced bullying, while 68.9% had suicide ideation at presentation. While controlling for age, gender, grade, psychiatric diagnosis, and abuse, a history of bullying was the most significant predictor of suicidal ideation. Individuals in this study who reported cyber bullying were 11.5 times more likely to have suicidal ideation documented on presentation, while individuals reporting verbal bullying were 8.4 times more likely.

CONCLUSIONS

The prevalence of bullying in adolescent patients presenting to emergency departments is high. The relationship found between suicidal ideation and bullying demonstrates that clinicians should ask questions about bullying as a risk factor for suicide ideation during the assessment of children and adolescents.

A preliminary investigation into the design of pressure cushions and their potential applications for forearm robotic orthoses

BACKGROUND

Load cells are often used in rehabilitation robotics to monitor human-robot interaction. While load cells are accurate and suitable for the stationary end-point robots used in rehabilitation hospitals, their cost and inability to conform to the shape of the body hinder their application in developing affordable and wearable robotic orthoses for assisting individuals in the activities of daily living. This exploratory work investigates the possibility of using an alternative technology, namely compliant polymeric air cushions, to measure interaction forces between the user and a wearable rigid structure.

METHODS

A polymeric air cushion was designed, analyzed using a finite element model (FEM), and tested using a bench-top characterization system. The cushions underwent repeatability testing, and signal delay testing from a step response while increasing the length of the cushion's tubes. Subsequently, a 3D printed wrist brace prototype was integrated with six polymeric air cushions and tested in static conditions where a volunteer exerted isometric pronation/supination torque and forces in vertical and horizontal directions. The load measured by integrating data recorded by the six sensors was compared with force data measured by a high quality load cell and torque sensor.

RESULTS

The FEM and experimental data comparison was within the error bounds of the external differential pressure sensor used to monitor the pressure inside the cushion. The ratio obtained experimentally between the pressure inside the pressure cushion and the 8 N applied load deviated by only 1.28% from the FEM. A drift smaller than 1% was observed over 10 cycles. The rise times of the cushion under an 8 N step response for a 0.46, 1.03, and 2.02 m length tube was 0.45, 0.39, and 0.37 s. Tests with the wrist brace showed a moderate root mean square error (RMSE) between the force estimated by the pressure cushions and the external load cells. Specifically, the RMSE was 13 mNm, 500 mN, and 1.24 N for forearm pronation/supination torque, vertical force, and horizontal force, respectively.

CONCLUSIONS

The use of compliant pressure cushions was shown to be promising for monitoring interaction forces between the forearm and a rigid brace. This work lays the foundation for the future design of an array of pressure cushions for robotic orthoses. Future research should also investigate the compatibility of these polymeric cushions for data acquisition during functional magnetic resonance imaging in shielded rooms.

Outcomes of involuntary hospital admission. Satisfaction with treatment and the effect of involuntary admissions on patients

Introduction

Involuntary hospitalization in those presumed to be mentally ill has been a common practice. Although some patients are hospitalized for aggression, two-thirds of the patients are hospitalized because of the threat they pose to themselves. Although these patients require risk assessment and evaluation for possible presence of mental illness, the question is how much these patients will benefit from involuntary admission and what the long-term outcome would be.

Method

All patients admitted involuntary to the psychiatric ward in Kingston, Canada, and psychiatrists involved in their care were interviewed to see whether they think the involuntary admission was helpful. All patients were asked to fill-out MacArthur AES to assess their satisfaction with hospitalization.

Results

Although psychiatrists frequently reported that the admission was justified, only 29 out of 81 patients reported being explained to why they had been admitted involuntarily. Also, there was a significant difference in AES scores between those who were and were not given an explanation for admission. In addition, psychiatrists more often reported that the involuntary admission worsened the therapeutic relationship which was significantly associated with involuntary admission that was not explained to patients.

Discussion

The results of our study shows that patients admitted involuntarily often feel disappointed with staff and mental health system. It could lead to feeling of hopelessness, frustration and low self-esteem. If explained, some patients who present with risk to self might accept voluntary admissions, that will improve therapeutic alliance with psychiatrists and increase satisfaction from hospitalization. Result of this study could improve the decision making process for involuntary admissions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

What is commonly missed in the suicidal risk assessments in the emergency room?

Introduction

Suicidal behaviour remains the most common reason for presentation to the emergency rooms. In spite of identifiable risk factors, suicide remains essentially unpredictable by current tools and assessments. Moreover, some factors may not be included consistently in the suicidal risk assessments in the emergency room by either emergency medicine physicians or psychiatrists.

Method

Step 1 involved the administration of a survey on the importance of suicide predictors for assessment between psychiatry and emergency medicine specialties. In step 2 a chart review of psychiatric emergency room patients in Kingston, Canada was conducted to determine suicide predictor documentation rates. In step 3, based on the result of the first 2 steps a suicide risk assessment tool (Suicide RAP [Risk Assessment Prompt]) was developed and presented to both teams. A second patient chart review was conducted to determine the effectiveness of the educational intervention and suicide RAP in suicide risk assessment.

Results

Significant differences were found in the rating of importance and the documentation rates of suicide predictors between the two specialties. Several predictors deemed important, have low documentation rates. Thirty of the suicide predictors showed increased rates of documentation after the educational intervention and the presentation of the suicide RAP.

Conclusion

Though a surfeit of information regarding patient risk factors for suicide is available, clinicians and mental health professionals face difficulties in integrating and applying this information to individuals. Based on the result of this study suicide RAP and educational intervention could be helpful in improving the suicidal risk assessment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Comparison of parental socio-demographic factors in children and adolescents presenting with internalizing and externalizing disorders

OBJECTIVE

This study aimed to: (a) examine parental socio-demographic factors in children and adolescents referred to an outpatient service for internalizing and externalizing disorders, and (b) compare the demographic variables and diagnoses for the two diagnostic groups.

METHODS

Parents of all children who were referred to the child and adolescent outpatient service were asked to participate. Following their informed consent, they completed a socio-demographic questionnaire for themselves and a Child Behaviour Checklist (CBCL) for their child. The CBCL scores and the diagnoses assigned by the psychiatrists were then recorded for each child. Diagnoses were classified as internalizing or externalizing based on the primary DSM-IV diagnosis assigned by the psychiatrists. Data for the two groups were compared for study variables using Pearson correlation, t-tests, one-way ANOVA and logistic regression.

RESULTS

Children who had externalizing disorders tended to live with unemployed single parents who had lower education levels and lived in rented or assisted housing. Children with internalizing problems tended to live in owned homes with employed parents. There was no significant association between age or gender for either group.

CONCLUSION

Previous literature has reported an association between low SES and more mental health problems; however, the relationship between different indicators of SES and diagnosis is not clear. Despite small numbers, our study revealed significant differences between the parental socio-demographic factors for externalizing compared with internalizing disorders.

Improving oxidative stability of olive oil: Incorporation of Spirulina and evaluation of its synergism with citric acid

The effects of different Spirulina concentrations used alone and in combination with citric acid on the oxidative stability of olive oil were assessed. The amounts of primary and secondary oxidation products produced in Spirulina samples were lower than that of the control. The improved oxidative stability indices of Spirulina samples with and without citric acid were in the range of 85.20–94.47% and 258.10–260.21%, respectively. In comparison with the control, Spirulina samples manifested significantly higher carotenoid and chlorophyll contents at the beginning and end of the storage period. The presence of these bioactive compounds results from the presence of Spirulina in the medium and can thus retard the oxidation of olive oil. A higher oxidative stability was reached using BHT in comparison with Spirulina samples. Furthermore, no synergistic action was observed in possible connections between citric acid and Spirulina. In conclusion, Spirulina can enhance oxidative stability and improve the shelf life of olive oil.

Effectiveness of online versus live multi-family psychoeducation group therapy for children and adolescents with mood or anxiety disorders: a pilot study

OBJECTIVE

[1] To highlight the effectiveness of multi-family psychoeducation group therapy (MFPGT) in children with mood or anxiety disorders; [2] to measure change in knowledge and awareness of mood and anxiety disorders in families and children; and [3] to compare the relative effectiveness of online compared to live MFPGT.

METHOD

Participants included families of children (12 years or younger) referred with a mood or anxiety disorder to the Division of Child and Adolescent Psychiatry at Queen's University (n=16) who were on a waitlist to see a psychiatrist. Change was measured through questionnaires for all parents before and after the program. Using SPSS v22, comparisons between the online (n=6) and live (n=10) groups were made using the Mann-Whitney U test and within group comparisons were made using Wilcoxon signed-rank test.

RESULTS

The online and live education groups showed similar overall improvements in knowledge acquisition and expressed emotion in participating families. However, statistical significance must be interpreted with caution due to the small sample size.

CONCLUSIONS

Online MFPGT may be an effective way to increase knowledge, provide resources and support and build on skills thus giving individuals more control and confidence when dealing with a mood or anxiety disorder while on a waitlist. MFPGT showed equal efficacy in live and online groups, indicating that the online program has the potential to be a more convenient and accessible program for families. More research is needed with a greater sample size.

Bimanual elbow exoskeleton: Force based protocol and rehabilitation quantification

An aging population, along with the increase in cardiovascular disease incidence that accompanies this demographic shift, is likely to increase both the economic and medical burden associated with stroke in western societies. Rehabilitation, the standard treatment for stroke, can be expanded and augmented with state of the art technologies, such as robotic therapy. This paper expands upon a recent work involving a force-feedback master-slave bimanual exoskeleton for elbow rehabilitation, named a Bimanual Wearable Robotic Device (BWRD). Elbow force data acquired during the execution of custom tasks is analyzed to demonstrate the feasibility of tracking patient progress. Two training tasks that focus on applied forces are examined. The first is called "slave arm follow", which uses the absolute angular impulse as a metric; the second is called "conditional arm static", which uses the rise time to target as a metric, both presented here. The outcomes of these metrics are observed over three days.

Bullying Victimization (Being Bullied) Among Adolescents Referred for Urgent Psychiatric Consultation: Prevalence and Association With Suicidality

OBJECTIVE

To examine the prevalence of bullying victimization among adolescents referred for urgent psychiatric consultation, to study the association between bullying victimization and suicidality, and to examine the relation between different types of bullying and suicidality.

METHOD

A retrospective chart review was conducted for all adolescents referred to a hospital-based urgent consultation clinic. Our study sample consisted of adolescents with a history of bullying victimization. The Research Ethics Board of Queen's University provided approval. Data analysis was conducted using SPSS (IBM SPSS Inc, Armonk, NY). Chi-square tests were used for sex, suicidal ideation, history of physical and sexual abuse, and time and type of bullying, and an independent sample t test was used for age.

RESULTS

The prevalence of bullying victimization was 48.5% (182 of 375). There was a significant association between being bullied and suicidal ideation (P = 0.01), and between sex and suicidal ideation (P ≤ 0.001). Victims of cyberbullying reported more suicidal ideation than those who experienced physical or verbal bullying (P = 0.04).

CONCLUSIONS

Bullying victimization, especially cyberbullying, is associated with increased risk of suicidal ideation among adolescents referred for psychiatric risk assessment. The detailed history of the type and duration of bullying experienced by the victims should be considered when conducting a psychiatric risk assessment.

Comparison of national gestational weight gain guidelines and energy intake recommendations

Although data showing adverse effects with high and low gestational weight gain (GWG) come from a large number of countries, a variety of guidelines about the GWG exist. Our objectives were to compare existing GWG and energy recommendations across various countries, as well as the rationale or evidence on which they were based. We used the United Nations' Human Developmental Index to determine the ranking of the country to ensure broad sampling and then searched for guidelines. We first searched the national government websites, and if necessary searched Medline and EMBASE, Global Health databases, and bibliographies of published articles for both guidelines and the studies on which they were based. We found guidelines for 31% of the countries, and 59% of these had a GWG recommendation, 68% had an energy intake recommendation (EIR), and 36% had both. About half of the GWG guidelines are similar to the 2009 American Institutes of Medicine (IOM) and 73% of the EIRs are similar to the 2006 IOM. Despite the documented relationship between both high GWG and adverse outcomes for women and infants and low GWG and adverse outcomes in infants, there are a wide variety of guidelines for GWG and energy recommendations by different countries around the world.

Gender differences in life events prior to onset of major depressive disorder: the moderating effect of age

Theoretical models attempting to explain why approximately twice as many women as men suffer from depression often involve the role of stressful life events. However, detailed empirical evidence regarding gender differences in rates of life events that precede onset of depression is lacking, due in part to the common use of checklist assessments of stress that have been shown to possess poor validity. The present study reports on a combined sample of 375 individuals drawn from 4 studies in which all participants were diagnosed with major depressive disorder and assessed with the Life Events and Difficulties Schedule (Bifulco et al., 1989), a state-of-the-art contextual interview and life stress rating system. Women reported significantly more severe and nonsevere, independent and dependent, and other-focused and subject-focused life events prior to onset of depression than did men. Further, these relations were significantly moderated by age, such that gender differences in rates of most types of events were found primarily in young adulthood. These results are discussed in term of their implications for understanding the etiological role of stressful life events in depression.

Preferred patterns of diastolic timed vibrations for pre-hospitalization treatment of acute coronary ischemia

This paper presents and evaluates preferred patterns of vibrations and active breaking techniques for the Diastolic Timed Vibrator (DTV). DTV uses low frequency mechanical vibrations applied to the chest to help in clot dissolution in pre-hospitalization treatment of acute coronary ischemia. In this work, we argue that random and ramp type vibration patterns increase the performance of the DTV method. Furthermore, we present results for various methods of vibration stopping aiming at reduction of vibration overspill into the systole of heart cycle of the patient.