Therapist-supported Internet cognitive behavioural therapy for anxiety disorders in adults

A Schema Therapy-Based eHealth Program for Patients with Borderline Personality Disorder (priovi): Naturalistic Single-Arm Observational Study

BACKGROUND

Electronic health (eHealth) programs have been found to be effective in treating many psychological conditions. However, regarding borderline personality disorder (BPD), only a few eHealth programs have been tested, involving small interventions based on the dialectical behavior therapy treatment approach. We investigated priovi, a program based on the schema therapy (ST) approach. priovi is considerably more comprehensive than prior programs, offering broad psychoeducation content and many therapeutic exercises.

OBJECTIVE

We tested the acceptability and feasibility of priovi in 14 patients with BPD as an add-on to individual face-to-face ST.

METHODS

Patients received weekly individual ST and used priovi over a period of 12 months. We assessed BPD symptom severity using self-reported and interview-based measures. Qualitative interviews were conducted with both patients and therapists to assess their experiences with priovi.

RESULTS

BPD symptoms improved significantly (Cohen d=1.0). Overall, qualitative data showed that priovi was positively received by both patients and therapists. Some exercises provoked mild anxiety; however, no serious threat to safety was detected.

CONCLUSIONS

priovi is a potentially helpful and safe tool that could support individual ST. It needs to be further tested in a randomized controlled study.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00011538; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00011538 (Archived by WebCite at http://www.webcitation.org/74jb0AgV8).

Association Between Anxiety, Depression, and Post-traumatic Stress Disorder and Outcomes After Ischemic Stroke

Background: Stroke patients are known to be at risk of developing anxiety, depression, and post-traumatic stress disorder (PTSD). Objective: To determine the overlap between anxiety, depression, and PTSD in patients after stroke and to determine the association between these disorders and quality of life, functional status, healthcare utilization, and return to work. Methods: A cross-sectional telephone survey was conducted to assess for depression, anxiety, PTSD, and health-related outcomes 6-12 months after first ischemic stroke in patients without prior psychiatric disease at a single stroke center. Results: Of 352 eligible subjects, 55 (16%) completed surveys. Seven subjects (13%) met criteria for probable anxiety, 6 (11%) for PTSD, and 11 for depression (20%). Of the 13 subjects (24%) who met criteria for any of these disorders, 6 (46%) met criteria for more than one, and 5 (39%) met criteria for all three. There were no significant differences in baseline characteristics, including stroke severity or neurologic symptoms, between those with or without any of these disorders. Those who had any of these disorders were less likely to be independent in their activities of daily living (ADLs) (54 vs. 95%, p < 0.001) and reported significantly worse quality of life (score of 0-100, median score of 50 vs. 80, p < 0.001) compared to those with none of these disorders. Conclusions: Anxiety, depression, and PTSD are common after stroke, have a high degree of co-occurrence, and are associated with worse outcomes, including quality of life and functional status.

Predicting Adherence to Internet-Delivered Psychotherapy for Symptoms of Depression and Anxiety After Myocardial Infarction: Machine Learning Insights From the U-CARE Heart Randomized Controlled Trial

BACKGROUND

Low adherence to recommended treatments is a multifactorial problem for patients in rehabilitation after myocardial infarction (MI). In a nationwide trial of internet-delivered cognitive behavior therapy (iCBT) for the high-risk subgroup of patients with MI also reporting symptoms of anxiety, depression, or both (MI-ANXDEP), adherence was low. Since low adherence to psychotherapy leads to a waste of therapeutic resources and risky treatment abortion in MI-ANXDEP patients, identifying early predictors for adherence is potentially valuable for effective targeted care.

OBJECTIVES

The goal of the research was to use supervised machine learning to investigate both established and novel predictors for iCBT adherence in MI-ANXDEP patients.

METHODS

Data were from 90 MI-ANXDEP patients recruited from 25 hospitals in Sweden and randomized to treatment in the iCBT trial Uppsala University Psychosocial Care Programme (U-CARE) Heart study. Time point of prediction was at completion of the first homework assignment. Adherence was defined as having completed more than 2 homework assignments within the 14-week treatment period. A supervised machine learning procedure was applied to identify the most potent predictors for adherence available at the first treatment session from a range of demographic, clinical, psychometric, and linguistic predictors. The internal binary classifier was a random forest model within a 3×10-fold cross-validated recursive feature elimination (RFE) resampling which selected the final predictor subset that best differentiated adherers versus nonadherers.

RESULTS

Patient mean age was 58.4 years (SD 9.4), 62% (56/90) were men, and 48% (43/90) were adherent. Out of the 34 potential predictors for adherence, RFE selected an optimal subset of 56% (19/34; Accuracy 0.64, 95% CI 0.61-0.68, P<.001). The strongest predictors for adherence were, in order of importance, (1) self-assessed cardiac-related fear, (2) sex, and (3) the number of words the patient used to answer the first homework assignment.

CONCLUSIONS

For developing and testing effective iCBT interventions, investigating factors that predict adherence is important. Adherence to iCBT for MI-ANXDEP patients in the U-CARE Heart trial was best predicted by cardiac-related fear and sex, consistent with previous research, but also by novel linguistic predictors from written patient behavior which conceivably indicate verbal ability or therapeutic alliance. Future research should investigate potential causal mechanisms and seek to determine what underlying constructs the linguistic predictors tap into. Whether these findings replicate for other interventions outside of Sweden, in larger samples, and for patients with other conditions who are offered iCBT should also be investigated.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22).

The effectiveness of guided internet-based cognitive behavioral therapy for social anxiety disorder in a routine care setting

Social anxiety disorder (SAD) is a common mental disorder with high persistence when untreated. As access to effective treatment is limited, guided internet-based cognitive behavioral therapy (ICBT) has been proposed as an effective alternative to face-to-face treatment. In this study, we examined the effectiveness of a 14-week therapist-guided ICBT program for patients with SAD undergoing routine care. From 2014 to 2017, 169 patients were included in the study, of which 145 started the treatment. The sample was all general practitioner-referred and had a lower educational level and higher rate of work absence compared to similar effectiveness studies. Regarding social anxiety symptoms, we identified significant within-group effect sizes (post-treatment: d = 1.00-1.10; six-month follow-up: d = 1.03-1.55). We also found significant effects on secondary depression symptoms (d = 0.67). Clinically significant improvement was reported by 66.2% of the participants, and 16.6% had a significant deterioration. Clinical implications of the current study are that guided ICBT for SAD is an effective treatment for the majority of the patients undergoing routine care. Future studies should explore interventions targeting non-responders and deteriorated patients.

Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial

Transdiagnostic internet-delivered cognitive behavioural therapies (iCBT) are effective for treating anxiety and depression, but there is room for improvement. In this study we developed a new Mindfulness-Enhanced iCBT intervention by incorporating formal and informal mindfulness exercises within an existing transdiagnostic iCBT program for mixed depression and anxiety. We examined the acceptability, feasibility, and outcomes of this new program in a sample of 22 adults with anxiety disorders and/or major depression. Participants took part in the 7-lesson clinician-guided online intervention over 14 weeks, and completed measures of distress (K-10), anxiety (GAD-7), depression (PHQ-9), mindfulness (FFMQ) and well-being (WEMBWS) at pre-, mid-, post-treatment, and three months post-treatment. Treatment engagement, satisfaction, and side-effects were assessed. We found large, significant reductions in distress (Hedges g = 1.55), anxiety (g = 1.39), and depression (g = 1.96), and improvements in trait mindfulness (g = 0.98) and well-being (g = 1.26) between baseline and post-treatment, all of which were maintained at follow-up. Treatment satisfaction was high for treatment-completers, with minimal side-effects reported, although adherence was lower than expected (59.1% completed). These findings show that it is feasible to integrate online mindfulness training with iCBT for the treatment of anxiety and depression, but further research is needed to improve adherence. A randomised controlled trial is needed to explore the efficacy of this program.

ICBT in routine care: A descriptive analysis of successful clinics in five countries

Clinical trials have demonstrated the efficacy of internet delivered cognitive behaviour therapy (ICBT) for anxiety and depression. However, relatively little is known about the context, operations, and outcomes of ICBT when administered as part of routine care. This paper describes the setting, relationship to existing health services, procedures for referral, assessment, treatment, patients and outcomes of ICBT clinics in Sweden, Denmark, Norway, Canada and Australia. All five clinics provide services free or at low cost to patients. All have systems of governance to monitor quality of care, patient safety, therapist performance and data security. All five clinics include initial assessments by clinicians and between 10 and 20 min of therapist support during each week. Published reports of outcomes all demonstrate large clinical improvement, low rates of deterioration, and high levels of patient satisfaction. Services that require a face to face assessment treat smaller numbers of patients and have fewer patients from remote locations. The paper shows that therapist-guided ICBT can be a valuable part of mental health services for anxiety and depression. Important components of successful ICBT services are rigorous governance to maintain a high standard of clinical care, and the measurement and reporting of outcomes.

Review of Use of Asynchronous Technologies Incorporated in Mental Health Care

PURPOSE OF REVIEW

Mental health clinicians should understand how technologies augment, enhance, and provide alternate means for the delivery of mental healthcare. These technologies can be used asynchronously, in which the patient and the clinician need not be communicating at the same time. This contrasts with synchronous technologies, in which patient and clinician must communicate at the same time.

RECENT FINDINGS

The review is based on research literature and the authors' clinical and healthcare administration experiences. Asynchronous technologies can exist between a single clinician and a single patient, such as patient portal e-mail and messaging, in-app messaging, asynchronous telepsychiatry via store-and-forward video, and specialty patient-to-provider mobile apps. Asynchronous technologies have already been used in different countries with success, and can alleviate the psychiatric workforce shortage and improve barriers to access. Multiple studies referred to in this review demonstrate good retention and acceptability of asynchronous psychotherapy interventions by patients. Asynchronous technologies can alleviate access barriers, such as geographical, scheduling, administrative, and financial issues. It is important for clinicians to understand the efficacy, assess the ethics, and manage privacy and legal concerns that may arise from using asynchronous technologies.

Moving to Beat Anxiety: Epidemiology and Therapeutic Issues with Physical Activity for Anxiety

PURPOSE OF REVIEW

The purpose of this paper was to provide a comprehensive narrative review of the relationship between physical activity (PA) and anxiety and the rationale for including it as a treatment option for anxiety disorders. Several gaps in the literature are highlighted alongside recommendations for future research.

RECENT FINDINGS

PA in the general population has established efficacy in preventing and managing cardiovascular disease and improving wellbeing. Recent epidemiological data further suggests that people who are more active may be less likely to have anxiety disorders. In addition, evidence from systematic reviews of randomised control trials suggests that exercise training, a subset of PA, can reduce symptoms in anxiety and stress-related disorders, such as post-traumatic stress disorder, agoraphobia and panic disorder. Anxiety disorders are common, burdensome and costly to individuals and wider society. In addition to the profound negative impact on individuals' wellbeing and functioning, they are associated with worsened physical health, including a higher risk for cardiovascular diseases and premature mortality. Although pharmacotherapy and psychological interventions are helpful for many, these treatment approaches are not effective for everyone and are insufficient to address common physical health complications, such as the elevated risk of cardiovascular disease. Given the combined anxiolytic and physical health benefits of increased activity, PA presents a promising additional treatment option for people with anxiety disorders. However, there remain key gaps in the literature regarding the mechanisms underlying the effects of PA, optimal PA protocols, methods of improving adherence and the importance of physical fitness. These must be addressed for PA to be successfully implemented in mental health services.

Facilitating the Dissemination of iCBT for the Treatment of Anxiety and Depression: A Feasibility Study

Translating existing internet-based cognitive-behavioural therapy (iCBT), along with the use of transdiagnostic and self-guided formats, may prove to be a cost-effective option of disseminating iCBT. Only recently have encouraging findings been reported for a self-guided delivery. This study assessed the feasibility of a French and self-guided version of an existing English iCBT course, called the Wellbeing Course, for the treatment of anxiety and depression. Existing ICBT programs have not yet been delivered in French, although this language is spoken worldwide. Thirty-one participants were included in a single group pre-post open trial with a 3-month follow-up. Feasibility outcomes were attrition, treatment adherence, acceptability, and preliminary efficacy. Primary outcome measures were the Patient Health Questionnaire 9-item (PHQ-9) and the Generalised Anxiety Disorder 7-item (GAD-7). Nearly 75% of the participants completed the program. Over 80% of the participants provided posttreatment and follow-up data. All study completers reported that they would recommend the Wellbeing Course to a friend having similar problems. Significant reductions in symptoms of anxiety and depression were found following treatment, consistent with earlier studies. These preliminary findings support the use of the assessed strategies to facilitate the cross-cultural dissemination of iCBT for a more universal access to quality psychological care.

Digital Technologies in the Treatment of Anxiety: Recent Innovations and Future Directions

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the efficacy, limitations, and future of e-health treatments for anxiety. Within this, we provide detail on "first-generation" e-health approaches, such as computerized therapies. Additionally, we assess the emergence and early efficacy of newer methods of treatment delivery, including smartphone apps and virtual reality interventions, discussing the potential and pitfalls for each.

RECENT FINDINGS

There is now substantial clinical research demonstrating the efficacy of internet-delivered cognitive behavioral therapy in the treatment of anxiety. However, the ability of these interventions for engaging patients in "real-world" settings is unclear. Recently, smartphone apps for anxiety have presented a more popular and ubiquitous method of intervention delivery, although the evidence base supporting these newer approaches drastically falls behind the extensive marketing and commercialization efforts currently driving their development. Meanwhile, the increasing availability of novel technologies, such as "virtual reality" (VR), introduces further potential of e-health treatments for generalized anxiety and anxiety-related disorders such as phobias and obsessive compulsive disorder, while also creating additional challenges for research. Although still in its infancy, e-health research is already presenting several promising avenues for delivering effective and scalable treatments for anxiety. Nonetheless, several important steps must be taken in order for academic research to keep pace with continued technological advances.

Public Attitudes Toward Guided Internet-Based Therapies: Web-Based Survey Study

BACKGROUND

Internet interventions have been proposed to improve the accessibility and use of evidence-based psychological treatments. However, little is known about attitudes toward such treatments, which can be an important barrier to their use.

OBJECTIVE

This study aimed to (1) determine attitudes toward guided internet interventions, (2) assess its acceptability compared with other internet-based formats, and (3) explore predictors of acceptance.

METHODS

A convenience-sample Web-based survey (N=646) assessed attitudes toward guided internet therapies (ie, perceived usefulness and helpfulness, and advantage relative to face-to-face therapy), preferences for delivery modes (ie, e-preference: guided internet interventions, unguided internet interventions, or videoconferencing psychotherapy), and potential predictors of attitudes and preferences: sociodemographics, help-seeking-related variables, attachment style, and perceived stress.

RESULTS

Although most participants perceived internet interventions as useful or helpful (426/646, 65.9%), a few indicated their advantage relative to face-to-face therapy (56/646, 8.7%). Most participants preferred guided internet interventions (252/646, 39.0%) over videoconferencing psychotherapy (147/646, 22.8%), unguided internet interventions (124/646, 19.2%), and not using internet interventions (121/646, 18.8%; missing data: 1/646, 0.2%). Attachment avoidance and stress were related to e-preference (all P<.05). Moreover, preference for therapist-guided internet interventions was higher for individuals who were aware of internet-based treatment (χ²₆=12.8; P=.046).

CONCLUSIONS

Participants assessed therapist-guided internet interventions as helpful, but not equivalent to face-to-face therapies. The vast majority (523/646, 81.0%) of the participants were potentially willing to use internet-based approaches. In lieu of providing patients with only one specific low-intensity treatment, implementation concepts should offer several options, including guided internet interventions, but not limited to them. Conversely, our results also indicate that efforts should focus on increasing public knowledge about internet interventions, including information about their effectiveness, to promote acceptance and uptake.

Who benefits most from therapist-assisted internet-delivered cognitive behaviour therapy in clinical practice? Predictors of symptom change and dropout

Internet-delivered cognitive behavioral therapy (ICBT) is effective for treating anxiety and depression, but not for all patients. Predictors of dropout and outcomes from ICBT remain unclear and the literature could benefit from study of response to ICBT among larger community samples using advanced statistical techniques. In this study, we sought to identify predictors of dropout and symptom change in a large community sample (n = 1201) who received therapist-assisted transdiagnostic ICBT targeting anxiety and/or depression. Logistic regression was used to assess dropout, and showed that those who fully completed ICBT lessons (n = 880) were older and endorsed lower psychological distress at intake than those who only partially completed ICBT lessons (n = 321). During the course of therapy, patients responded to the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 at six time points. Autoregressive latent trajectory models were fitted to this data to assess the ability of demographic variables, program engagement, psychological and medical service usage, and psychological distress to explain individual variance in initial symptom levels and symptom change over time. Higher symptom scores at pre-treatment were predictive of greater symptom improvement. Symptom improvement was greater in those who were off work on disability and those without higher post-secondary education. Clinical implications are discussed.

Implementing internet-delivered cognitive behavior therapy for common mental health disorders: A comparative case study of implementation challenges perceived by therapists and managers in five European internet services

OBJECTIVE

Internet-delivered cognitive behavior therapy programs have been developed and evaluated in randomized controlled trials during the past two decades to alleviate the rising demand for effective treatment of common mental health disorders such as anxiety and depression. While most of the research on internet-based cognitive behavior therapy (iCBT) has focused on efficacy and effectiveness only little attention has been devoted to the implementation of iCBT. The aim of this study was to identify the main implementation challenges perceived by therapists and managers involved in the practical operation of iCBT services in routine care settings in five European countries.

METHOD

The study was designed as a multiple comparative case study to explore differences and similarities between five different iCBT services in Sweden, Norway, Denmark, The Netherlands and Scotland. Field visits were carried out to each of the five services including interviews with the management of the service (n = 9), focus group interviews with key staff (n = 15) and demonstration of online programs. The data material was processed through thematic, comparative analysis.

RESULTS

The analysis generated four transversal themes: 1) integration in the mental health care system; 2) recruitment of patients; 3) working practice of therapists; and 4) long-term sustainability of service. The main results concerned the need to address the informal integration in the health care systems related to the perceived skepticism towards iCBT from GPs and face-to-face therapists, the role of referral models and communication strategies for the stable recruitment of patients, the need for knowledge, standards and material for the training of therapists in the provision of online feedback, the need to improve the possibilities to tailor programs to individual patients, and the need for considerate long-term sustainability planning of the transitions from local projects to permanent regional or national services.

CONCLUSION

The present study gives an overview of the main implementation challenges regarding the practical operation of iCBT services perceived by the therapists and managers of the iCBT services. Future studies into specific details of each challenge will be important to strengthen the evidence base of iCBT and to improve uptake and implementation of iCBT in routine care.

Effectiveness of a transdiagnostic individually tailored Internet-based and mobile-supported intervention for the indicated prevention of depression and anxiety (ICare Prevent) in Dutch college students: study protocol for a randomised controlled trial

Background

Depression and anxiety are common and co-morbid disorders that affect a significant proportion of students. Innovative prevention strategies targeting both conditions are needed to reduce their health burden and costs. ICare Prevent is such an innovative strategy and contains a transdiagnostic individually tailored Internet-based and mobile-supported intervention. It addresses common risk factors of depression and anxiety as part of a large EU-funded multi-country project* (ICare). Little is known about the clinical and cost-effectiveness of this type of intervention compared to care as usual (CAU) for college students. We hypothesize that ICare Prevent will be more (cost-)effective than CAU in the reduction of symptoms of depression and anxiety.

Methods

A three-arm, parallel, randomized controlled superiority trial will be conducted comparing a guided and an unguided version of ICare Prevent with a control group receiving CAU. The trial will be open-label but outcome assessors will be blinded. A total of 252 college students (age ≥ 16 years) with subclinical symptoms of depression defined as a score ≥ 16 on the Center for Epidemiological Studies Depression Scale (CES-D), and/or anxiety, defined as a score ≥ 5 on the Generalized Anxiety Disorder scale (GAD-7), will be included. Those meeting diagnostic criteria for a depressive or anxiety disorder will be excluded. The primary outcome is change in disorder specific symptom severity from baseline to post-intervention. Secondary endpoints include self-reported depression and anxiety symptoms as well as time to onset of a mood or anxiety disorder until 12-month follow-up. Societal costs and quality of life will be assessed to estimate the intervention’s cost-effectiveness compared to CAU.

Discussion

Transdiagnostic individually tailored Internet-based prevention could be a (cost-)effective approach to tackle the disease burden of depression and anxiety among college students.

Trial registration

Dutch trial register, NTR 6562. Registered on 6 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2477-y) contains supplementary material, which is available to authorized users.

A study protocol for a non-randomised comparison trial evaluating the feasibility and effectiveness of a mobile cognitive-behavioural programme with integrated coaching for anxious adults in primary care

INTRODUCTION

Generalised anxiety disorder (GAD) and subclinical GAD are highly prevalent in primary care. Unmanaged anxiety worsens quality of life in patients seen in primary care practices and leads to increased medical utilisation and costs. Programmes that teach patients cognitive-behavioural therapy (CBT) techniques have been shown to improve anxiety and to prevent the evolution of anxiety symptoms to disorders, but access and engagement have hampered integration of CBT into medical settings.

METHODS AND ANALYSIS

This pragmatic study takes place in University of Pittsburgh Medical Center primary care practices to evaluate a coach-supported mobile cognitive- behavioural programme (Lantern) on anxiety symptoms and quality of life. Clinics were non-randomly assigned to either enhanced treatment as usual or Lantern. All clinics provide electronic screening for anxiety and, within clinics assigned to Lantern, patients meeting a threshold level of mild anxiety (ie, >5 on Generalised Anxiety Disorder 7-Item Questionnaire (GAD-7)) are referred to Lantern. The first study phase is aimed at establishing feasibility, acceptability and effectiveness. The second phase focuses on long-term impact on psychosocial outcomes, healthcare utilisation and clinic/provider adoption/sustainable implementation using a propensity score matched parallel group study design. Primary outcomes are changes in anxiety symptoms (GAD-7) and quality of life (Short-Form Health Survey) between baseline and 6-month follow-ups, comparing control and intervention. Secondary outcomes include provider and patient satisfaction, patient engagement, durability of changes in anxiety symptoms and quality of life over 12 months and the impact of Lantern on healthcare utilisation over 12 months. Patients from control sites will be matched to the patients who use the mobile app.

ETHICS AND DISSEMINATION

Ethics and human subject research approval were obtained. A data safety monitoring board is overseeing trial data and ethics. Results will be communicated to participating primary care practices, published and presented at clinical and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03035019.

The acceptability of an Internet-based exposure treatment for flying phobia with and without therapist guidance: patients' expectations, satisfaction, treatment preferences, and usability

PURPOSE

Internet-based treatments have been tested for several psychological disorders. However, few studies have directly assessed the acceptability of these self-applied interventions in terms of expectations, satisfaction, treatment preferences, and usability. Moreover, no studies provide this type of data on Internet-based treatment for flying phobia (FP), with or without therapist guidance. The aim of this study was to analyze the acceptability of an Internet-based treatment for FP (NO-FEAR Airlines) that includes exposure scenarios composed of images and real sounds. A secondary aim was to compare patients' acceptance of two ways of delivering this treatment (with or without therapist guidance).

PATIENTS AND METHODS

The sample included 46 participants from a randomized controlled trial who had received the self-applied intervention with (n = 23) or without (n = 23) therapist guidance. All participants completed an assessment protocol conducted online and by telephone at both pre- and posttreatment.

RESULTS

Results showed good expectations, satisfaction, opinion, and usability, regardless of the presence of therapist guidance, including low aversiveness levels from before to after the intervention. However, participants generally preferred the therapist-supported condition.

CONCLUSION

NO-FEAR Airlines is a well-accepted Internet-based treatment that can help enhance the application of the exposure technique, improving patient acceptance and access to FP treatment.

Dropping out of a transdiagnostic online intervention: A qualitative analysis of client's experiences

INTRODUCTION

An important concern in Internet-based treatments (IBTs) for emotional disorders is the high dropout rate from these protocols. Although dropout rates are usually reported in research studies, very few studies qualitatively explore the experiences of patients who drop out of IBTs. Examining the experiences of these clients may help to find ways to tackle this problem.

METHOD

A Consensual Qualitative Research study was applied in 10 intentionally-selected patients who dropped out of a transdiagnostic IBT.

RESULTS

22 categories were identified within 6 domains. Among the clients an undeniable pattern arose regarding the insufficient support due to the absence of a therapist and the lack of specificity of the contents to their own problems.

CONCLUSIONS

The analyzed content has direct impact on the clinical application of IBTs. A more tailored manage of expectations as well as strategies to enhance the therapeutic relationship in certain clients are identified as the two key elements in order to improve the dropout in IBTs. Going further, in the mid and long run, ideographic interventions would be vital. The present study permits to better grasp the phenomenon of dropout in IBTs and delineate specific implications both in terms of research, training and practice.

The effectiveness of unguided internet cognitive behavioural therapy for mixed anxiety and depression

Clinician-guided internet-delivered cognitive behavioral therapy (iCBT) is an effective treatment for depression and anxiety disorders. However, few studies have examined the effectiveness of completely unguided iCBT. The current research investigated adherence to, and the effects of two brief unguided iCBT programs on depression and anxiety symptom severity, and psychological distress. Study 1 evaluated a four-lesson transdiagnostic iCBT program for anxiety and depression (N = 927). Study 2 then evaluated a three-lesson version of the same program (N = 5107) in order to determine whether reducing the duration of treatment would influence adherence and treatment effects. Cross-tabulations and independent t-tests were used to examine the extent to which users adhered and remitted with treatment. Linear mixed models were used to evaluate the effects of treatment in the entire sample, and stratified by gender and completer-type (e.g., users who completed some but not all lessons vs. those who completed all lessons of treatment). Among those who began treatment, 13.83% completed all four lessons in Study 1. Shortening the course to three lessons did not improve adherence (e.g., 13.11% in Study 2). In both studies, users, on average, experienced moderate to large effect size reductions in anxiety and depressive symptom severity, as well as psychological distress. This pattern of results was robust across gender and for those who did and did not complete treatment. Approximately two-thirds of those who completed treatment experienced remission. These data show that unguided iCBT programs, which have the capacity to attract large numbers of individuals with clinically significant symptoms of depression and anxiety, and psychological distress, can produce significant improvements in wellbeing.

Efficacy of Seren@ctif, a Computer-Based Stress Management Program for Patients With Adjustment Disorder With Anxiety: Protocol for a Controlled Trial

BACKGROUND

Adjustment disorder with anxiety (ADA) is the most frequent and best characterized stress-related psychiatric disorder. The rationale for prescription of benzodiazepine monotherapy is a public health issue. Cognitive behavioral stress management programs have been studied in many countries. Several reports have shown beyond reasonable doubt their efficiency at reducing perceived stress and anxiety symptoms and improving patient quality of life. Considering the number of people who could benefit from such programs but are unable to access them, self-help programs have been offered. First presented as books, these programs became enriched with computer-based and digital supports. Regrettably, programs for stress management based on cognitive behavioral therapy (CBT), both face-to-face and digital support, have been only minimally evaluated in France. To our knowledge, the Seren@ctif program is the first French language self-help program for stress management using digital supports.

OBJECTIVE

The aim of this study is to assess the effectiveness of a 5-week standardized stress management program for reducing anxiety conducted via eLearning (iCBT) or through face-to-face interviews (CBT) with patients suffering from ADA compared with a wait list control group (WLC). These patients seek treatment in a psychiatric unit for anxiety disorders at a university hospital. The primary outcome is change in the State Trait Anxiety Inventory scale trait subscale (STAI-T) between baseline and 2-month visit.

METHODS

This is a multicenter, prospective, open label, randomized controlled study in 3 parallel groups with balanced randomization (1:1:1): computer-based stress management with minimal contact (not fully automated) (group 1), stress management with face-to-face interviews (group 2), and a WLC group that receives usual health care from a general practitioner (group 3). Programs are based on standard CBT principles and include 5 modules in 5 weekly sessions that include the following topics: stress and stress reaction and assessment; deep respiration and relaxation techniques; cognitive restructuring, mindfulness, and acceptance; behavioral skills as problem solving; and time management, healthy behaviors, and emotion regulation. In the Internet-based group, patients have minimal contact with a medical professional before and after every session. In the first session, a flash memory drive is supplied containing videos, audio files, a self-help book portfolio in the form of an eGuide, and log books providing the exercises to be completed between 2 sessions. The patient is encouraged to practice a 20-minute daily exercise 5 or 6 times per week. In the face-to-face group, patients receive the same program from a therapist with 5 weekly sessions without digital support. Interviews and self-assessments were collected face-to-face with the investigator.

RESULTS

The feasibility of this program is being tested, and results show good accessibility in terms of acceptance, understanding, and treatment credibility. Results are expected in 2018.

CONCLUSIONS

To our knowledge, this is the first French study to examine the effectiveness of a computer-based stress management program for patients with ADA. The Seren@ctif program may be useful within the framework of a psychoeducative approach. It could also be advised for people suffering from other diseases related to stress and for people with a clinical level of perceived stress.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02621775; https://clinicaltrials.gov/ct2/show/NCT02621775 (Archived by WebCite at http://www.webcitation.org/6tQrkPs1u).

Web-based therapeutic interventions for assessing, managing and treating health conditions in Indigenous people: a scoping review protocol

REVIEW OBJECTIVES/QUESTIONS

The objective of the scoping review is to map the international scientific literature on web-based therapeutic interventions (WBTI) used by Indigenous people for assessing, managing and treating health conditions. The focus of this review is WBTIs for a broad range of health conditions, including but not limited to, communicable and non-communicable diseases, mental health conditions (including the broader concept of social and emotional wellbeing), use of harmful substances and gambling.The questions for the scoping review are.

Internet- and mobile-based aftercare and follow-up for mental disorders: protocol of a systematic review and meta-analysis

INTRODUCTION

Mental disorders are characterised by a high likelihood of symptom recurrence or chronicity. Thus, in the vulnerable post-discharge phase, aftercare and follow-up aim at stabilising treatment effects, promoting functionality and preventing relapse or readmission. Internet- and mobile-based interventions may represent low threshold and effective extensions to aftercare in tertiary prevention of mental disorders.

OBJECTIVES

The planned systematic review and meta-analysis aims to synthesise and analyse existing evidence on the effectiveness of psychological internet- and mobile-based aftercare or follow-up in maintaining treatment effects and/or preventing recurrence in adults with mental disorders.

METHODS AND ANALYSIS

Electronic databases (PsycInfo, MEDLINE and Cochrane Central Register of Controlled trials) will be searched systematically, complemented by a hand-search of ongoing trials and reference lists of selected studies. Data extraction and evaluation will be conducted by two independent researchersand quality will be assessed with the Cochrane risk of bias tool. Eligibility criteria for selecting studies will be: randomised controlled trials of internet-based and mobile-based, psychological aftercare and follow-up for the tertiary prevention of mental disorders in an adult population. Primary outcome will be symptom severity. Secondary outcomes will be symptom or disorder recurrence rate, rehospitalisation rate, functionality, quality of life or adherence to primary treatment. Further data items to be extracted will be: study design, intervention and technical characteristics, type of mental disorder or clinical symptom to be treated, target population items, setting, treatment engagement and assessment of additional outcome variables. Meta-analytic pooling will be conducted when data of included studies are comparable in terms of study design, intervention type, endpoints, assessments and target mental disorder. Cumulative evidence will be evaluated according to the Grading of Recommendations Assessment, Development and Evaluation framework.

ETHICS AND DISSEMINATION

Ethics approval is not required. Results from this review will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42017055289.

Fifteen Challenges in Establishing a Multidisciplinary Research Program on eHealth Research in a University Setting: A Case Study

Background

U-CARE is a multidisciplinary eHealth research program that involves the disciplines of caring science, clinical psychology, health economics, information systems, and medical science. It was set up from scratch in a university setting in 2010, funded by a governmental initiative. While establishing the research program, many challenges were faced. Systematic documentation of experiences from establishing new research environments is scarce.

Objective

The aim of this paper was to describe the challenges of establishing a publicly funded multidisciplinary eHealth research environment.

Methods

Researchers involved in developing the research program U-CARE identified challenges in the formal documentation and by reflecting on their experience of developing the program. The authors discussed the content and organization of challenges into themes until consensus was reached.

Results

The authors identified 15 major challenges, some general to establishing a new research environment and some specific for multidisciplinary eHealth programs. The challenges were organized into 6 themes: Organization, Communication, Implementation, Legislation, Software development, and Multidisciplinarity.

Conclusions

Several challenges were faced during the development of the program and several accomplishments were made. By sharing our experience, we hope to help other research groups embarking on a similar journey to be prepared for some of the challenges they are likely to face on their way.

Web-Based Cognitive Behavior Therapy for Depression in People With Diabetes Mellitus: A Randomized Controlled Trial

Background

Depression is twice as common in diabetes mellitus (DM) as the general population and is associated with adverse health outcomes, but access to evidence-based therapies such as cognitive behavioral therapy (CBT) is limited in routine diabetes care. Past research has shown that generic Internet-based cognitive behavioral therapy (iCBT) is an effective treatment for depression in the general population, but it has never been evaluated in people with comorbid depression and DM.

Objective

The aim of our study was to examine the efficacy of a generic 6-lesson iCBT delivered over 10 weeks in people with major depressive disorder (MDD) and DM.

Methods

Participants with comorbid MDD and DM (type 1 or 2) were recruited online and randomized to an iCBT program with therapist support provided by phone and email (n=42) or a treatment as usual (TAU, n=49) control group. Outcomes were assessed through Web-based self-report questionnaires and the trial was Web-based with no face-to-face components. Primary outcomes were self-reported depression (patient health questionnaire-9, PHQ-9), diabetes-related distress (problem areas in diabetes, PAID), and self-reported glycemic control (hemoglobin A1c, HbA1c). Secondary outcomes were general distress (Kessler 10-item psychological distress scale, K-10) and disability (short form 12-item, SF-12), generalized anxiety (generalized anxiety disorder 7-item, GAD-7), and somatization (PHQ-15). The iCBT group was assessed at 3 months.

Results

A total of 27 participants (66%; 27/41) completed the iCBT program. Analyses indicated between-group superiority of iCBT over TAU at posttreatment on PHQ-9 (g=0.78), PAID (g=0.80), K-10 (g=1.06), GAD-7 (g=0.72), and SF-12 mental well-being scores (g=0.66), but no significant differences in self-reported HbA1c levels (g=0.14), SF-12 physical well-being, or PHQ-15 scores (g=0.03-0.21). Gains were maintained at 3-month follow-up in the iCBT group, and the 87% (27/31) of iCBT participants who were interviewed no longer met criteria for MDD. Clinically significant change following iCBT on PHQ-9 scores was 51% (21/41) versus 18% (9/49) in TAU.

Conclusions

iCBT for depression is an efficacious, accessible treatment option for people with diabetes. Future studies should explore whether tailoring of iCBT programs improves acceptability and adherence, and evaluate the long-term outcomes following iCBT.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ACTRN): 12613001198718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365208&isReview=true (Archived by WebCite at http://www.webcitation.org/6qCR8Fi9V)

Public Acceptability of E-Mental Health Treatment Services for Psychological Problems: A Scoping Review

BACKGROUND

Over the past decades, the deficient provision of evidence-based interventions for the prevention and treatment of mental health problems has become a global challenge across health care systems. In view of the ongoing diffusion of new media and mobile technologies into everyday life, Web-delivered electronic mental health (e-mental health) treatment services have been suggested to expand the access to professional help. However, the large-scale dissemination and adoption of innovative e-mental health services is progressing slowly. This discrepancy between potential and actual impact in public health makes it essential to explore public acceptability of e-mental health treatment services across health care systems.

OBJECTIVE

This scoping review aimed to identify and evaluate recent empirical evidence for public acceptability, service preferences, and attitudes toward e-mental health treatments. On the basis of both frameworks for technology adoption and previous research, we defined (1) perceived helpfulness and (2) intentions to use e-mental health treatment services as indicators for public acceptability in the respective general population of reviewed studies. This mapping should reduce heterogeneity and help derive implications for systematic reviews and public health strategies.

METHODS

We systematically searched electronic databases (MEDLINE/PubMed, PsycINFO, Psyndex, PsycARTICLES, and Cochrane Library, using reference management software for parallel searches) to identify surveys published in English in peer-reviewed journals between January 2010 and December 2015, focusing on public perceptions about e-mental health treatments outside the context of clinical, psychosocial, or diagnostic interventions. Both indicators were obtained from previous review. Exclusion criteria further involved studies targeting specific groups or programs.

RESULTS

The simultaneous database search identified 76 nonduplicate records. Four articles from Europe and Australia were included in this scoping review. Sample sizes ranged from 217 to 2411 participants of ages 14-95 years. All included studies used cross-sectional designs and self-developed measures for outcomes related to both defined indicators of public acceptability. Three surveys used observational study designs, whereas one study was conducted as an experiment investigating the impact of brief educational information on attitudes. Taken together, the findings of included surveys suggested that e-mental health treatment services were perceived as less helpful than traditional face-to-face interventions. Additionally, intentions to future use e-mental health treatments were overall smaller in comparison to face-to-face services. Professional support was essential for help-seeking intentions in case of psychological distress. Therapist-assisted e-mental health services were preferred over unguided programs. Unexpectedly, assumed associations between familiarity with Web-based self-help for health purposes or "e-awareness" and intentions to use e-mental health services were weak or inconsistent.

CONCLUSIONS

Considering the marginal amount and heterogeneity of pilot studies focusing on public acceptability of e-mental health treatments, further research using theory-led approaches and validated measures is required to understand psychological facilitator and barriers for the implementation of innovative services into health care.

Current Views and Perspectives on E-Mental Health: An Exploratory Survey Study for Understanding Public Attitudes Toward Internet-Based Psychotherapy in Germany

BACKGROUND

Despite the advanced development of evidence-based psychological treatment services, help-seeking persons with mental health problems often fail to receive appropriate professional help. Internet-delivered psychotherapy has thus been suggested as an efficient strategy to overcome barriers to access mental health care on a large scale. However, previous research indicated poor public acceptability as an issue for the dissemination of Internet-delivered therapies. Currently, little is known about the expectations and attitudes toward Internet-delivered therapies in the general population. This is especially the case for countries such as Germany where electronic mental health (e-mental health) treatment services are planned to be implemented in routine care.

OBJECTIVE

This pilot study aimed to determine the expectations and attitudes toward Internet-based psychotherapy in the general population in Germany. Furthermore, it aimed to explore the associations between attitudes toward Internet-based therapies and perceived stress.

METHODS

To assess public attitudes toward Internet-based psychotherapy, we conducted both Web-based and paper-and-pencil surveys using a self-developed 14-item questionnaire (Cronbach alpha=.89). Psychological distress was measured by employing a visual analogue scale (VAS) and the 20-item German version of the Perceived Stress Questionnaire (PSQ). In addition, we conducted explorative factor analysis (principal axis factor analysis with promax rotation). Spearman's rank correlations were used to determine the associations between attitudes toward Internet-based therapies and perceived stress.

RESULTS

Descriptive analyses revealed that most respondents (N=1558; female: 78.95%, 1230/1558) indicated being not aware of the existence of Internet-delivered therapies (83.46%, 1141/1367). The average age was 32 years (standard deviation, SD 10.9; range 16-76). Through exploratory factor analysis, we identified 3 dimensions of public attitudes toward Internet-based therapies, which we labeled "usefulness or helpfulness," "relative advantage or comparability," and "accessibility or access to health care." Analyses revealed negative views about Internet-based therapies on most domains, such as perceived helpfulness. The study findings further indicated ambivalent attitudes: Although most respondents agreed to statements on expected improvements in health care (eg, expanded access), we observed low intentions to future use of Internet-delivered therapies in case of mental health problems.

CONCLUSIONS

This pilot study showed deficient "e-awareness" and rather negative or ambivalent attitudes toward Internet-delivered therapies in the German-speaking general population. However, research targeting determinants of the large-scale adoption of Internet-based psychotherapy is still in its infancy. Thus, further research is required to explore the "black box" of public attitudes toward Internet-delivered therapies with representative samples, validated measures, and longitudinal survey designs.

Acceptability of an internet cognitive behavioural therapy program for people with early-stage cancer and cancer survivors with depression and/or anxiety: thematic findings from focus groups

PURPOSE

We developed an eight-lesson internet-delivered CBT (iCBT) program targeting anxiety and depression in early-stage cancer and cancer survivors. To explore the acceptability of the program, we showed volunteers the first two lessons and asked for their views.

METHODS

Focus groups (n = 3) and individual interviews (n = 5) were undertaken with 15 participants (11 survivors) with mainly breast (11 of the 15) cancer, who had reviewed intervention materials. Participants were asked to consider the acceptability of the iCBT program content and implementation design (timing, duration). Semi-structured questions guided discussion. Thematic analysis was conducted of participant reactions to the acceptability and/or suitability of materials created for use in a psychological intervention. We took a data-driven (inductive) approach to semantic theme development across the data set.

RESULTS

Participants reported high acceptability of the internet delivery format, good engagement and user-friendly material. Participants were broadly supportive of combining depression and anxiety iCBT resources for early-stage cancer patients and survivors. Participants further indicated that a separate course would be needed to address the needs of patients with advanced stage disease.

CONCLUSIONS

Participants welcomed the general development of an internet-delivered CBT intervention program to treat patients with clinical depression and/or anxiety. Furthermore, the sessions reviewed were highly acceptable to all participants. Study findings informed researchers on the development of iCBT resources for the cancer community.

Anxiety

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions-including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal-is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Distance-delivered interventions for PTSD: A systematic review and meta-analysis

This systematic review and meta-analysis evaluated the efficacy of distance-delivered, guided approaches to treatment (e.g., delivered via telephone, Internet, mail, videoconferencing) for clinical and subclinical posttraumatic stress disorder (PTSD). A comprehensive search yielded 19 randomized controlled trials (1491 participants) to be included. Meta-analyses revealed that distance-delivered interventions led to significant within-group improvements in PTSD symptoms at post-treatment (g=0.81, 95% CI 0.65 to 0.97) and 3-6 month follow-up (g=0.78, 95% CI 0.59 to 0.97). Within-group depression and quality of life outcomes showed similar results, with medium post-treatment and follow-up effects. Compared to a waiting list, distance delivery (specifically, Internet treatments) led to superior PTSD outcomes (g=0.68, 95% CI 0.51 to 0.86). Compared to face-to-face interventions, distance delivery (specifically, videoconferencing treatments) did not result in significantly different PTSD outcomes at post-treatment (g=-0.05, 95% CI -0.31 to 0.20) but led to inferior outcomes at 3-6 month follow-up (g=-0.25, 95% CI -0.44 to -0.07). Distance delivery of PTSD treatment is promising, but research is needed to determine its optimal use.

Features and functionality of the Iterapi platform for internet-based psychological treatment

The purpose of this article is to describe an internet-based platform for improving symptoms and quality of life for people with psychological and behavioural health problems such as depression, anxiety, phobia, psychological trauma, hearing loss and tinnitus. The online platform, called Iterapi, was developed at the Department of Behavioural Sciences and Learning at Linköping University, Sweden and has been running for nearly two decades and used in many randomized controlled trials and outpatient treatments. The intention of this article is to share our experience with developing such a treatment solution and the process flow and elements of running internet-based psychological interventions. This will likely be of use to developers building similar services, therapists considering integrating such approaches in their practices and institutions, as well as researchers curious about the functions included on the platform and methodology used for running studies. We describe the security aspects of the platform, central concepts underlying its development, how the platform can be used in a study or treatment and the main features and functions the platform offers. We comment on practical considerations regarding blending of methods within the platform, such as self-help treatments with asynchronous communication and real-time text chat and video conversations. We also point out the advantages of using Internet-assisted treatments, the challenges that we have faced and future planned upgrades. Due to continuous development of the platform, its user-friendliness, accessibility across devices and numerous features, many research colleagues from Sweden as well as other countries such as Germany, United Kingdom, Romania and Israel have chosen to implement their own studies on the platform.

Smartphone-Based Psychotherapeutic Micro-Interventions to Improve Mood in a Real-World Setting

BACKGROUND

Using mobile communication technology as new personalized approach to treat mental disorders or to more generally improve quality of life is highly promising. Knowledge about intervention components that target key psychopathological processes in terms of transdiagnostic psychotherapy approaches is urgently needed. We explored the use of smartphone-based micro-interventions based on psychotherapeutic techniques, guided by short video-clips, to elicit mood changes.

METHOD

As part of a larger neurofeedback study, all subjects-after being randomly assigned to an experimental or control neurofeedback condition-underwent daily smartphone-based micro-interventions for 13 consecutive days. They were free to choose out of provided techniques, including viscerosensory attention, emotional imagery, facial expression, and contemplative repetition. Changes in mood were assessed in real world using the Multidimensional Mood State Questionnaire (scales: good-bad, GB; awake-tired, AT; and calm-nervous, CN).

RESULTS

Twenty-seven men participated on at least 11 days and were thus included in the analyses. Altogether, they underwent 335, generally well-tolerated, micro-intervention sessions, with viscerosensory attention (178 sessions, 53.13%) and contemplative repetition (68 sessions, 20.30%) being the most frequently applied techniques. Mixed models indicated that subjects showed better mood [GB: b = 0.464, 95%confidence interval (CI) [0.068, 0.860], t (613.3) = 2.298, p = 0.022] and became more awake [AT: b = 0.514, 95%CI [0.103, 0.925], t (612.4) = 2.456, p = 0.014] and calmer [CN: b = 0.685, 95%CI [0.360, 1.010], t (612.3) = 4.137, p < 0.001] from pre- to post-micro-intervention. These mood improvements from pre- to post-micro-intervention were associated with changes in mood from the 1st day until the last day with regard to GB mood (r = 0.614, 95%CI [0.297, 0.809], p < 0.001), but not AT mood (r = 0.279, 95%CI [-0.122, 0.602], p = 0.167) and CN mood (r = 0.277, 95%CI [0.124, 0.601], p = 0.170).

DISCUSSION

Our findings provide evidence for the applicability of smartphone-based micro-interventions eliciting short-term mood changes, based on techniques used in psychotherapeutic approaches, such as mindfulness-based psychotherapy, transcendental meditation, and other contemplative therapies. The results encourage exploring these techniques' capability to improve mood in randomized controlled studies and patients. Smartphone-based micro-interventions are promising to modify mood in real-world settings, complementing other psychotherapeutic interventions, in line with the precision medicine approach. The here presented data were collected within a randomized trial, registered at ClinicalTrials.gov (Identifier: NCT01921088) https://clinicaltrials.gov/ct2/show/NCT01921088.

Behavioral health support and online peer communities: international experiences

Online peer support communities play an important part in many people's experience of healthcare. They can be particularly significant in behavioral health/mental health due to the difficulties that people may experience in accessing face to face care for these conditions. There is considerable diversity of practice in service management, target group, and moderation practices of online peer support communities. People using the communities also appear to have diverse aims and experiences. This heterogeneity contributes to a relative lack of data about the value and effectiveness of online peer support in behavioral health, although there is significant research into some aspects of these communities. The digital behavioral health service Big White Wall was launched in the UK in 2007, and in the US in 2015, and is focused on delivering moderated peer support. There are considerable differences in health systems between the two countries, and this has been reflected in different experiences of implementation. The value of online peer support could be maximized if systemic challenges to implementation and adoption were addressed more effectively.