[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]

[Efficacy of internet-based interventions for depression available in Germany-A systematic review and meta-analysis]

BACKGROUND

Internet-based interventions (IBIs) for the treatment of depression have been found to have positive effects in international meta-analyses; however, it is unclear whether these effects also extend to IBIs specifically available in Germany. The aim of this meta-analysis was to estimate the immediate effects and the long-term effects of IBIs available in Germany free of charge or available on prescription and covered by the public health insurances as so-called digital health applications (DiGAs) and to compare the efficacy of DiGAs and freely available IBIs.

METHOD

A systematic literature search and random-effects meta-analysis were performed (preregistration: INPLASY202250070). Randomized controlled trials (RCTs) of IBIs freely available in Germany or as DiGA in adults with elevated depressive symptoms were compared with active and inactive controls available at the time of the survey in May 2022.

RESULTS

A total of six interventions were identified: COGITO, deprexis, iFightDepression, moodgym, Novego, and Selfapy. The pooled effect size of a total of 28 studies with 13,413 participants corresponded to an effect of Cohen's d = 0.42, (95% confidence interval, CI: 0.31-0.54, I2 = 81%). The analysis of long-term effects showed a smaller effect size of d = 0.29, (95% CI: 0.21-0.37, I2 = 22%, N = 10). Subgroup analyses indicated a possible superiority of the three interventions listed in the DiGA directory (d = 0.56, 95% CI: 0.38-0.74, I2 = 83%, N = 15) compared to the three freely available IBIs (d = 0.24, 95% CI: 0.14-0.33, I2 = 44%, N = 13, p = 0.002).

CONCLUSION

The IBIs for depressive disorders available in Germany are effective and can therefore be used in the treatment of people with a depressive disorder; however, it is possible that not all interventions are equally effective.

A mobile-based aftercare intervention to increase self-esteem in inpatients diagnosed with depression: A randomized controlled trial

OBJECTIVE

In this randomized controlled trial, we investigated the effectiveness, side effects and user satisfaction of the self-help smartphone app "MCT & More" among inpatients with a diagnosis of depression after their discharge from a psychiatric hospital over a period of 4 weeks.

METHODS

A total of 159 inpatients were recruited in four German psychiatric hospitals three days before hospital discharge (intervention group: n = 79; treatment as usual: n = 80). Based on the vulnerability model (low self-esteem contributes to depression), self-esteem represented the primary outcome, quality of life and depressive symptoms the secondary outcomes.

RESULTS

Intention-to-treat analyzes showed no statistical significance for the primary and secondary outcome parameters, except for the subscale self-competence in favor of the intervention group (with a small effect size of d = 0.35), in the context of an exploratory approach (post hoc). The more positive the attitude toward mobile-based interventions and the more positive the treatment expectations, the more frequently the app was used (r = .35, p = .008; r = .34, p = .009).

CONCLUSION

Further symptom reduction could not be obtained. However, the results suggest that an effect on improvement in self-competence could be achieved by low-threshold aftercare programs. Future studies should include long-term assessments to examine the impact of mobile-based aftercare on relapse.Trial registration: DRKS00022559.

Construction of a three-level enteral nutrition nursing system under the "Internet + medical" mode and an evaluation of its effect in clinical application

Objective

This study aimed to explore the construction of a three-level enteral nutrition nursing system under the "Internet + medical" mode and the clinical application effect.

Methods

A total of 40 nurses from four primary and secondary hospitals in Jiangxi Province and 100 patients treated with enteral nutrition between January 2020 and December 2021 were enrolled in this study. Patients in the control group received routine enteral nutrition nursing. In the study group, a three-level enteral nutrition nursing system was applied under the "Internet + medical" mode to train and guide the implementation of clinical enteral nutrition. The changes in nurses' cognition and behavior in enteral nutrition safety nursing, comprehensive core competence before and after training, and the effect of enteral nutrition nursing were compared between the two groups.

Results

After 3 months of training, nurses' cognition and behavior scores in enteral nutrition safety nursing were higher than those before training (t = 11.780, P < 0.05), and nurses' core competence scores were higher than before training (P < 0.05). After 1 week of nursing, the nutritional risk screening 2002 (NRS2002) score decreased, and the levels of albumin and hemoglobin increased in both groups (P < 0.05). However, after 1 week of nursing, the NRS2002 score of the study group (2.89 ± 0.75) was lower than that of the control group (3.25 ± 0.82), and the levels of albumin (39.89 ± 3.21) and hemoglobin (119.57 ± 8.78) were higher in the study group than in the control group (albumin 36.25 ± 3.45, hemoglobin 113.66 ± 9.55) (P < 0.05).

Conclusion

Three-level enteral nutrition nursing linkage assisted by the "Internet + medical" mode can improve the cognition and behavior of medical staff in enteral nutrition safety nursing, as well as the comprehensive core competence of nurses, achieving good clinical effects.

[Quality Indicators for Video Consultations in Primary Care - a Scoping Review]

AIM

The German ban on remote treatment was relaxed in 2018. The SARS-CoV-2 pandemic ultimately ensured a surge in the implementation of video consultations as part of telemedicine in primary care. However, the question of how the quality of this form of care is represented is currently unanswered. The aim of this review was to identify criteria for assessing the quality of video consultations in primary care.

METHODS

As part of this review, a literature search was carried out in the databases PubMed, Web of Science, Google Scholar, Open Gray and Google. We searched for literature on quality criteria or quality indicators for telemedicine. German and English-language literature was included, there was no limit on publication date.

RESULTS

A total of 14 publications were included in the review. Out of the quality criteria identified, 13 quality indicators were derived. Of these, seven were for structural quality, two for process quality and four indicators for outcome quality. For instance, the switch to face-to-face treatment for those cases for which it was required, staff qualifications and access to this type of care were identified as possible indicators.

CONCLUSION

The quality indicators proposed in this article enable a structured evaluation of the quality of video consultations in primary care through their measurability. Further development of these indicators in order to define threshold values for the stated goals appears to be warranted.

A Positive Psychology Resource for Students? Evaluation of the Effectiveness of the 6 Minutes Diary in a Randomized Control Trial

This study investigated the effects of the 6 Minutes Journal (6MT), a commercial diary combining several positive psychology interventions, including gratitude, goal-setting, and self-affirmation exercises, on several mental health outcome measures. In a randomized controlled trial, university students (N = 157) were randomly assigned to one of two groups: 6MT (n = 77) and a wait list control group (n = 80). Participants in the intervention group were instructed to follow the instructions of the 6MT for 4 weeks. Participants in both groups completed measures of perceived stress, positive and negative affect, self-efficacy and resilience at baseline, after 2 (t1), and 4 (t2) weeks. We used path-analyses with autoregressive and cross-lagged effects to test our hypotheses of the effects of the 6MT. Participants in the intervention group reported decreased levels of perceived stress and negative affect, as well as increased levels of resilience and self-efficacy compared to the control group. Positive affect was not statistically significantly influenced. The data showed a statistically significant increased levels of self-efficacy and resilience only after 4 weeks, suggesting that changing these constructs needs more time. The 6-minute diary does not appear to make individuals fundamentally more positive. However, the intervention may have a protective function against negative influences on well-being.

Text Messaging Versus Email Messaging to Support Patients With Major Depressive Disorder: Protocol for a Randomized Hybrid Type II Effectiveness-Implementation Trial

BACKGROUND

Major depressive disorder (MDD) accounts for 40.5% of disability-adjusted life years caused by mental and substance use disorders. Barriers such as stigma and financial and physical access to care have been reported, highlighting the need for innovative, accessible, and cost-effective psychological interventions. The effectiveness of supportive SMS text messaging in alleviating depression symptoms has been proven in clinical trials, but this approach can only help those with mobile phones.

OBJECTIVE

This paper presents the protocol for a study that will aim to evaluate the feasibility, comparative effectiveness, and user satisfaction of daily supportive email messaging as an effective strategy compared to daily supportive text messaging as part of the treatment of patients with MDD.

METHODS

This trial will be carried out using a hybrid type II implementation-effectiveness design. This design evaluates the effectiveness of an implementation strategy or intervention, while also evaluating the implementation context associated with the intervention. Patients with MDD receiving usual care will be randomized to receive either daily supportive email messaging or daily supportive text messaging of the same content for 6 months. The Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the 5-item World Health Organization Well-Being Index will be used to evaluate the effectiveness of both strategies. The implementation evaluation will be guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, as well as the Consolidated Framework for Implementation Research. All outcome measures will be analyzed using descriptive and inferential statistics. Qualitative data will be analyzed using thematic analysis.

RESULTS

Data collection for this trial began in April 2021. We expect the study results to be available within 18 months of study commencement. The results will shed light on the feasibility, acceptability, and effectiveness of using automated emails as a strategy for delivering supportive messages to patients with MDD in comparison to text messaging.

CONCLUSIONS

The outcome of this trial will have translational impact on routine patient care and access to mental health, as well as potentially support mental health policy decision-making for health care resource allocation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04638231; https://clinicaltrials.gov/ct2/show/NCT04638231.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/29495.

[Digital health applications (DiGA) in medical and psychotherapeutic care. Opportunities and challenges from the perspective of the healthcare providers]

Since 2019, insured persons have a right by law to receive a prescription of digital health applications (DiGA). DiGA can be used in a variety of ways. Most healthcare providers are receptive to the possibilities of integration of DiGA into their treatment. In particular, the promotion of patient empowerment through DiGA is seen as a potential advantage by physicians and psychotherapists.However, from the healthcare provider's view, the preconditions for a successful integration of DiGA into the healthcare system are not yet fulfilled. The most important challenge that remains to be solved is the creation of acceptance and trust in a careful, producer-independent quality inspection of DiGA. Verified evidence on the effectiveness, interoperability, and data security of DiGA, as well as on the additional workload for providers, should be transparently available before they can be prescribed to patients. Furthermore, findings from health services research on the optimal integration of a DiGA into clinical workflow should be generated and integrated into the regulations. In addition, DiGA should be prescribed only if individual circumstances of the patient were considered.

A Mobile-Based Intervention to Increase Self-esteem in Students With Depressive Symptoms: Randomized Controlled Trial

Background

Depressive symptoms are one of the most common and ever-increasing mental health problems among students worldwide. Conventional treatment options, particularly psychotherapy, do not reach all students in need of help. Internet- and mobile-based interventions are promising alternatives for narrowing the treatment gap.

Objective

In the framework of a randomized controlled trial, we aim to investigate the effectiveness, acceptance, and side effects of a self-help smartphone app (MCT & More) based on cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and metacognitive training in a sample of students with self-reported depressive symptoms. Furthermore, we were interested in examining the influence of treatment expectations and attitudes toward internet- and mobile-based interventions on treatment adherence and effectiveness.

Methods

A total of 400 students were recruited via open access websites and randomized to either the intervention group (n=200), who received access to the self-help smartphone app MCT & More for a period of 4 weeks, or to a wait-list control group (n=200). The Patient Health Questionnaire-9 (depression) served as the primary outcome parameter, and the Rosenberg Self-esteem Scale (self-esteem) and the global item of the World Health Organization Quality of Life-abbreviated version (quality of life) served as the secondary outcome parameters. The Attitudes Towards Psychological Online Interventions was used to measure attitudes toward internet- and mobile-based interventions. Outcome expectations were assessed using the Patient Questionnaire on Therapy Expectation and Evaluation, and side effects were assessed using the Inventory for Assessing Negative Effects of Psychotherapy.

Results

Per-protocol (PP), complete-case, and intention-to-treat analyses showed a significantly higher reduction in depressive symptoms (PP: F_1,222=3.98; P=.047; d=0.26) and a significantly higher increase in self-esteem (PP: F_1,220=8.79; P=.003; d=0.40) in the intervention group than in the wait-list control group. Most participants regularly used the self-help smartphone app (91/120, 75.8%, at least once a week). The more positive the attitude toward internet- and mobile-based interventions (r=0.260; P=.004) and the more positive the outcome expectation (r=0.236; P=.009), the more frequently the self-help smartphone app was used.

Conclusions

The effectiveness of the self-help smartphone app MCT & More was demonstrated among students with depressive symptoms compared with a wait-list control group. The app could be offered regularly as a low-threshold intervention to enhance students’ health.

Trial Registration

German Clinical Trials Register DRKS00020941; https://tinyurl.com/pr84w6er

[Diagnostics and Therapy 24/7? Artificial Intelligence as a Challenge and Opportunity in Psychiatry and Psychotherapy]

OBJECTIVE

The aim of the article is to enable a fundamental understanding of the potentials and requirements of Artificial Intelligence (AI) for psychiatrists in the present and for the development of future working environments. Psychiatrists will need to understand the function of AI-systems and personalized AI-assistants in therapy systems and as part of their patients' daily life.

METHOD

The article provides an overview of basic categories and fields of application of AI and machine learning in the diagnosis, prevention and therapy of mental disorders.

RESULTS

AI-applications will shape the prevention, diagnosis and treatment as well as the basic etiological understanding of mental disorders. Notably, the treatment of mental disorders is significantly influenced by commercial product development and assistance systems outside the medical system, as the corresponding developments can exploit large data pools with significantly lower restrictions.

CONCLUSION

Psychiatrists should now seize the opportunity to actively shape the implementation of AI-systems as otherwise key competences could be transferred to a primary field outside the medical system to the detriment of the patient and the therapist.

Ethische Aspekte internet- und mobilgestützter Interventionen (IMIs) bei Suchtstörungen

Ziel der Studie Internet- und mobilgestützte Interventionen (IMIs) werden häufig bei Suchtstörungen eingesetzt. Für die Wirksamkeit von IMIs liegt eine umfangreiche Evidenz vor. Hinsichtlich der spezifischen ethischen Aspekte, die sich aus dem Einsatz von IMIs bei Suchtstörungen ergeben, fehlt es bislang an Forschung. Mit unserem Beitrag leisten wir die erste eingehende ethische Analyse von IMIs in der Suchttherapie. Dabei orientieren wir uns an normativen Aspekten, die spezifisch für die Behandlung von Suchtstörungen sind. Dazu gehören die besondere Stigmatisierung von Suchtkranken, die Zuschreibung von Schuld und Eigenverantwortung, die mangelnde Akzeptanz des Krankheitskonzepts Sucht sowie die daraus resultierende Ablehnung und Abwertung von Betroffenen.

Methode Als methodisches Instrument verwenden wir den 3 ACES-Ansatz von Thornicroft und Tansella. Dieses Instrument erlaubt eine umfassende ethische Analyse des Einsatzes von IMIs im konkreten Einzelfall sowie der Implementierung von IMIs im Versorgungssystem.

Ergebnisse Unsere Analyse zeigt, dass IMIs in der Suchttherapie das Potential haben, ein Empowerment von PatientInnen zu leisten, die Stigmatisierung zu umgehen und einen niedrigschwelligen Zugang zu Versorgungsleistungen zu ermöglichen. Kritisch zu sehen sind Aspekte der Passung von Anwendungen auf die Bedürfnisse einzelner Patientengruppen und individueller PatientInnen, der therapeutischen Verantwortung, des Datenschutzes, der Datensicherheit und Privatheit sowie der Vernetzung unterschiedlicher Anbieter von Versorgungsleistungen.

Schlussfolgerung Eine weitere Implementierung von IMIs in der Suchttherapie ist nur dann wünschenswert, wenn verbindliche Qualitätsstandards geschaffen und die patientenzentrierte Anwendung unter Berücksichtigung individueller Patientencharakteristika sichergestellt wird.

Adherence to Established Treatment Guidelines Among Unguided Digital Interventions for Depression: Quality Evaluation of 28 Web-Based Programs and Mobile Apps

Background

Web-based interventions for depression have been widely tested for usability and functioning. However, the few studies that have addressed the therapeutic quality of these interventions have mainly focused on general aspects without consideration of specific quality factors related to particular treatment components. Clinicians and scientists are calling for standardized assessment criteria for web-based interventions to enable effective and trustworthy patient care. Therefore, an extensive evaluation of web-based interventions at the level of individual treatment components based on therapeutic guidelines and manuals is needed.

Objective

The objective of this study was to evaluate the quality of unguided web-based interventions for depression at the level of individual treatment components based on their adherence to current gold-standard treatment guidelines and manuals.

Methods

A comprehensive online search of popular app stores and search engines in January 2018 revealed 11 desktop programs and 17 smartphone apps that met the inclusion criteria. Programs and apps were included if they were available for German users, interactive, unguided, and targeted toward depression. All programs and apps were tested by three independent researchers following a standardized procedure with a predefined symptom trajectory. During the testing, all web-based interventions were rated with a standardized list of criteria based on treatment guidelines and manuals for depression.

Results

Overall interrater reliability for all raters was substantial with an intraclass correlation coefficient of 0.73 and Gwet AC1 value of 0.80. The main features of web-based interventions included mood tracking (24/28, 86%), psychoeducation (21/28, 75%), cognitive restructuring (21/28, 75%), crisis management (20/28, 71%), behavioral activation (19/29, 68%), and relaxation training (18/28, 64%). Overall, therapeutic meaningfulness was rated higher for desktop programs (mean 4.13, SD 1.17) than for smartphone apps (mean 2.92, SD 1.46).

Conclusions

Although many exercises from manuals are included in web-based interventions, the necessary therapeutic depth of the interventions is often not reached, and risk management is frequently lacking. There is a need for further research targeting general principles for the development and evaluation of therapeutically sound web-based interventions for depression.

Smartphone applications for depression: a systematic literature review and a survey of health care professionals' attitudes towards their use in clinical practice

Smartphone applications ("apps") may contribute to closing the treatment gap for depression by reaching large populations at relatively low costs. The general public seems open towards the use of apps for mental disorders but less is known about the attitudes of health care professionals. Therefore, the aim of this study was to examine the available evidence on the effectiveness of apps for depression and to explore the attitudes of health care professionals towards their use in practice. A systematic literature search was performed aimed at studies utilizing smartphone applications for depression. In addition, a survey was conducted to explore health care professionals' attitudes towards using these treatment apps in clinical practice. Twelve articles were identified in the systematic literature review. All included trials reported a decline in depressive symptoms after the intervention periods. In the survey, 72 health care professionals participated. Significant differences were found between the level of technology experience and how much the health care professional would consider the use of mobile applications in clinical practice. Survey participants reported openness towards therapeutic app use but very little knowledge and experience in the field. Apps appear to be a promising self-management tool for reducing depressive symptoms. Despite some concerns, health care professionals' attitudes towards the use of smartphone applications in clinical practice are quite positive. The provision of information on the potential benefits of e-health interventions as well as the training of professionals in the application of new technologies may increase health care professionals' awareness and knowledge about mobile apps for the treatment of mental disorders.

[Who Benefits from the App? Internet- and Mobile-Based Interventions (IMIs) and the Tension between Autonomy and Patient Well-Being]

OBJECTIVE

The use of internet- and mobile-based interventions (IMIs) is often considered as empowerment of patients and improvement of accessibility of mental health services. Risks for specific patient groups are seldom discussed. Aim of the study is to identify patient groups that do not benefit from IMIs given the tension between autonomy and patient well-being.

METHODS

The ethical analysis is based on available empirical evidence (randomized control trials - RCTs, reviews) as well as ethical papers. Methodological background is the tension between patient autonomy and patient well-being, which is crucial to the therapeutic alliance. On this foundation, patient groups are identified that do not benefit from IMIs in terms of empowerment or accessibility.

RESULTS

The evidence-based ethical analysis shows that patients with certain disorders or high symptom severity, patients with low level of education or a lack of technical skills, and patients with a migrant background do often not benefit from IMIs. Risks of IMIs are a lack of individualization of interventions given individual treatment needs, symptom deterioration, higher dropout-rate, and insufficient identification of emergency situations.

DISCUSSION

Overemphasizing autonomy may compromize patient well-being in certain patient groups. This may lead to a situation where those patient groups whose inclusion into mental health service should be facilitated by IMIs might not be reached. These access barriers should be considered when designing IMIs, so that multimorbid marginalized groups are not forgotten in the necessary digitalization of the health market.

CONCLUSION

The application of IMIs depends on the individual resources of the patient. Should IMIs be further implemented within the German mental healthcare system, it is imperative that the patient well-being of those patient groups that do not benefit from IMIs is guaranteed. In addition, an early focus on marginalized groups may and the implementation of low-level access to counselling and treatment may provide chances for said groups.

How Do Publicly Available Allergy-Specific Web-Based Training Programs Conform to the Established Criteria for the Reporting, Methods, and Content of Evidence-Based (Digital) Health Information and Education: Thematic Content Evaluation

Background

Allergic diseases, such as allergic asthma, rhinitis, and atopic eczema, are widespread, and they are a considerable burden on the health care system. For patients and health care professionals, Web-based training programs may be helpful to foster self-management and provide allergy-specific information, given, for instance, their good accessibility.

Objective

This study aimed to assess an exploratory sample of publicly available allergy-specific Web-based training programs—that is, interactive, feedback-oriented Web-based training platforms promoting health behavior change and improvement of personal skills—with regard to (1) general characteristics, aims, and target groups and (2) the extent to which these tools meet established criteria for the reporting, methods, and content of evidence-based (digital) health information and education.

Methods

Web-based training programs were identified via an initial Google search and a search of English and German language websites of medical and public health services, such as the European Centre for Allergy Research Foundation (German), Asthma UK, and Anaphylaxis Canada. We developed a checklist from (1) established guidelines for Web-based health information (eg, the Journal of the American Medical Association benchmarks, DISCERN criteria, and Health On the Net code) and (2) a database search of related studies. The checklist contained 44 items covering 11 domains in 3 areas: (1) content (completeness, transparency, and evidence), (2) structure (data safety and qualification of trainers and authors), and (3) impact (effectiveness, user perspective, and integration into health care). We rated the Web-based training programs as completely, partly, or not satisfying each checklist item and calculated overall and domain-specific scores for each Web-based training program using SPSS 23.0 (SPSS Inc).

Results

The 15 identified Web-based training programs covered an average of 37% of the items (score 33 out of 88). A total of 7 Web-based training programs covered more than 40% (35/88; maximum: 49%; 43/88). A total of 5 covered 30% (26/88) to 40% (35/88) of all rated items and the rest covered fewer (n=3; lowest score 24%; 21/88). Items relating to intervention (58%; 10/18), content (49%; 9/18), and data safety (60%; 1/2) were more often considered, as opposed to user safety (10%; 0.4/4), qualification of staff (10%; 0.8/8), effectiveness (16%; 0.4/2), and user perspective (45%; 5/12). In addition, in 13 of 15 Web-based training programs, a minimum of 3 domains were not covered at all. Regarding evidence-based content, 46% of all Web-based training programs (7/15) scored on use of scientific research, 53% on regular information update (8/15), and 33% on provision of references (5/15). None of 15 provided details on the quality of references or the strength of evidence.

Conclusions

English and German language allergy-specific Web-based training programs, addressing lay audiences and health care professionals, conform only partly to established criteria for the reporting, methods, and content of evidence-based (digital) health information and education. Particularly, well-conducted studies on their effectiveness are missing.

Prospective acceptance of distinct mobile mental health features in psychiatric patients and mental health professionals

BACKGROUND

Despite numerous mobile health (mHealth) applications available, current impact on mental healthcare is low. Users face overwhelming variety of applications and sensors. Evidence for distinct features' effectiveness is largely lacking. Along with technical feasibility and data security issues, readiness and preferences of patients predetermine engagement and impact of mHealth in psychiatry.

OBJECTIVE

We aimed to assess the prospective attitudes of psychiatric patients and mental health professionals (MHP) towards mHealth applications in general and with regard to distinct features.

METHODS

We conducted a survey entailing 486 subjects (297 MHP and 189 patients).

RESULTS

Professionals and patients indicate both, considerable acceptance and rejection for most features. Marked concerns across groups relate to data security in general. Actimetry and geotracking were considered particularly skeptical. Importantly, most patients prefer to be prompted timely about health status changes.

CONCLUSION

Altogether, evidence indicates substantial support for mHealth features in mental healthcare despite considerable rejection of distinct features. We conclude that tighter collaboration between researchers, developers and clinicians must address matching mHealth-apps to patients' needs. Improved information on potential risks and possibilities associated with mHealth features is strongly indicated in MHP and psychiatric patients in order to reach an appropriately informed decision on individual involvement.

Proposing a standardized, step-by-step model for creating post-traumatic stress disorder (PTSD) related mobile mental health apps in a framework based on technical and medical norms

Background: Prevalence of post-traumatic stress disorder (PTSD) is a problem all over the world. There are high barriers for entry into formal psychotherapy, which results in a lack of mental health care for a significant part of the population. Mobile mental Health (mMHealth) applications (apps) seem to be a promising new development for countering this lack of care, building on the success of mHealth (Mobile Health) apps in general. Unfortunately, the overall quality of such apps stands in high contrast to their number. The aim of this manuscript is to propose a standard for creating PTSD-related mMHealth apps incorporating a process for evaluation and assessment of their usability and impact. Methods: This is done by first defining each step of the process and its relation to the other steps. The steps themselves, divided into those concerned with development, evaluation and implementation, are bound to the established medical and technical norms pertaining to them. Existing protocols from recent literature have been integrated into these steps. Results: As a result, a comprehensive model covering the process of creating, assessing and implementing an mMHealth app from start to finish was developed. The model may be adapted to other disorders or specialized for certain symptoms of PTSD. Conclusion: Adopting such a model could result in a 'blueprint' for creating mMHealth apps in a standardized way, thereby facilitating the testing and comparing of such apps.

[Quality criteria of internet-based cognitive-behavioral interventions for children and adolescents and their parents - A systematic review]

Quality criteria of internet-based cognitive-behavioral interventions for children and adolescents and their parents - A systematic review Abstract. Introduction: This study provides an overview of existing internet-based evidence-based cognitive behavioral interventions (iCBT) for children/adolescents and their parents. The studies were evaluated based on preliminary defined quality criteria regarding their usability in the healthcare system. Methods: The review was performed according to PRISMA guidelines and evaluated the scientific literature concerning to iCBT. We conducted a comprehensive literature search of PubMed, PsychINFO, PsychARTICLES, PsychNDEX and Science Direct using relevant keywords. Studies were rated according to 10 previously predefined quality measures. Results: A total of 4,479 articles were screened, 62 of which were selected for further analysis. Thereof, 24 international iCBT programs with 50 randomized controlled trials (RCTs) were evaluated and met the quality criteria (M = 7.25, SD = 1.07). Further 13 publications showed preliminary efficacy for another 11 international iCBT programs and met the quality criteria (M = 7.45, SD = .82). There was no significant difference between programs evaluated within and without RCTs t(33) = -.56, p = .58. Conclusions: Our results indicate that multiple international iCBT programs exist. Because in Germany the waiting time for psychotherapeutic or psychiatric treatment is still about five months, iCBT programs have the potential to reduce this gap.

Internet- and mobile-based aftercare and relapse prevention in mental disorders: A systematic review and recommendations for future research

BACKGROUND

Mental disorders are characterized by a high likelihood of recurrence. Thus, aftercare and follow-up interventions aim to maintain treatment gains and to prevent relapse. Internet- and mobile-based interventions (IMIs) may represent promising instruments in tertiary prevention. This systematic review summarizes and evaluates the research on the efficacy of IMIs as aftercare or follow-up interventions for adults with mental health issues.

METHODS

A systematic database search (PsycInfo, MEDLINE, CENTRAL) was conducted and studies selected according to predefined eligibility criteria (RCTs, adult population, clinical symptoms/disorder, assessed with validated instruments, clinical-psychological intervention rationale, aftercare/follow-up intervention, web-/mobile-based, minimum follow-up measurement of three months, inclusion of a control group). Inspected outcomes were symptom severity, recurrence- and rehospitalization rates, functioning, quality of life and adherence to primary treatment.Systematic review registration: PROSPERO CRD42017055289.

RESULTS

Sixteen RCTs met the inclusion criteria, covering trials on depression (n = 5), eating disorders (n = 4) and transdiagnostic interventions (n = 7). The majority of the interventions were based on Cognitive Behavioral Therapy (CBT) principles and were web-based (n = 11). Methodological quality of included studies was suboptimal. Limitations included attrition bias and non-specification of routine care co-interventions. IMIs yielded small to medium post-treatment effects for symptom severity (d = -0.08 - d = -0.45) in comparison to control groups. Best evidence base was found for symptom severity of depression and anxiety. Study results regarding recurrence and rehospitalization were inconsistent.

DISCUSSION

There is some evidence, that IMIs are feasible instruments for maintaining treatment gains for some mental disorders. However, further high quality, large-scale trials are needed to expand research fields, improve adherence to and uptake of IMIs and facilitate implementation of effective interventions into routine care.

Protocol for the REVISIT-BPD Trial, a Randomized Controlled Trial Testing the Effectiveness of an Internet-Based Self-Management Intervention in the Treatment of Borderline Personality Disorder (BPD)

Introduction: Borderline Personality Disorder (BPD) is a prevalent condition that is often under-treated. This is partly because very few psychotherapists offer treatment for this disabling disorder. Internet-based self-management interventions could contribute to reducing the treatment gap but-mainly due to safety concerns-these have never been tested for BPD in controlled trials. Methods: Patients with BPD will be recruited primarily via the internet and randomized to two groups: care as usual (CAU) alone) or the self-management intervention priovi® in addition to CAU. At the end of the diagnostic interview, all participants will discuss an emergency plan. The main outcome measure is the clinician-rated symptom severity using the BPD Severity Index (BPDSI). Secondary outcome measures include a range of self-reported scales, an SCID-diagnosis of BPD and several safety parameters including serious adverse events (e.g., a life-threatening event, hospitalization or suicide attempt). Discussion: This trial will evaluate the effectiveness of the self-management intervention, priovi, in reducing symptoms of BPD. It will also assess the safety of its use in this target population. If successful, this intervention would be the first comprehensive internet intervention for the treatment of BPD and complement the wide range of internet interventions effective in treating other mental disorders, particularly depression and anxiety disorders. Trial Registration: NCT03418142 (clinicaltrials.gov) on January 23rd 2018. Trial status: recruiting, currently N = 108 (July 2018).

GET.HAPPY - Acceptance of an internet-based self-management positive psychology intervention for adult primary care patients with mild and moderate depression or dysthymia: A pilot study

INTRODUCTION

A growing number of internet interventions have been shown to help in alleviating symptoms of depression. So far, only little research has focused on other methods than CBT. The present study aimed to investigate the level of satisfaction with a positive psychology online training among patients with mild and moderate depression or dysthymia. Secondary outcome measures included changes in symptom severity, health related quality of life, and negative effects.

METHODS

A total of 81 participants were allocated to the intervention. They were asked to complete online questionnaires and were called by one of the study psychologists at baseline, at post-treatment, and at follow-up (3 months after completion of the intervention). Shorter questionnaires were administered after each module.

RESULTS

Overall satisfaction was promising. While participants seemed to be very satisfied with many aspects of the program itself, they were slightly less satisfied with its impact on the problems they sought to solve. Overall, negative effects attributed to the program were small with one exception. At post-treatment, 22.6% of the participants felt that they or their problems were not taken seriously by the program. Symptom severity decreased over time with mild to moderate effect sizes. There was a moderate increase in satisfaction with mental health at both post-treatment and follow-up.

CONCLUSIONS

The online program investigated here may be a useful resource-oriented addition to the standard treatment of depression.

Barriers and facilitators for the implementation of blended psychotherapy for depression: A qualitative pilot study of therapists' perspective

INTRODUCTION

Blended therapies (BT) combine face-to-face (f2f) sessions with internet- and mobile-based interventions (IMIs). However, the use of blended interventions in routine care is still rare and depends on the acceptance of key health care professionals such as the therapists. Little is yet known about the therapists' perspective on and experiences with blended approaches. The aim of this pilot study was to identify barriers and facilitators, as perceived by psychotherapists, for implementing a blended therapy for depression.

METHODS

Semi-structured expert interviews were conducted with five therapists, who were part of the German study arm of the FP7-project E-Compared (www.e-compared.eu). All patients (N = 173) were treated in the context of a registered RCT (DRKS00006866) in which the clinical and cost-effectiveness of BT for depression, consisting of ten internet- and mobile-based cognitive behavioral therapy modules and six f2f sessions, was compared to the treatment usually provided by general practitioners. To identify barriers and facilitators an interview guide based on the theoretical domains framework (TDF) was developed. The interviews were audio-recorded, transcribed verbatim and analyzed using a qualitative content analysis by two independent coders.

RESULTS

The results revealed 29 barriers and 33 facilitators, which are hindering or enabling factors on the levels of 'implementation in the health care system', 'therapy', 'therapists' and 'patients'. Key barriers stated by all therapists were 'Limited customizability and autonomy of decisions concerning blending the therapy' (number of statements, k = 44); 'Disease-related contraindications for BT' (k = 25); 'Negative affect was caused by burden through technical problems' (k = 18); 'Limited number of f2f sessions hindered the therapy process'; and 'Establishment of therapeutic alliance was burdened by technical issues' (each k = 15). Key facilitators stated by all therapists were: 'Patients' interest, willingness and motivation to participate' (k = 22); 'Patients' access to online content between f2f sessions and after therapy end' (k = 20); 'Preset structure of IMI-part guided the treatment course of BT' (k = 18); and 'Effective help with BT in a short time frame' (k = 15), as well as 'Reduction of the treatment gap' (k = 13).

DISCUSSION

Therapists supported the implementation of BT for depression. Results indicated the consideration of a wide range of determinants: among others, the possibility of individualizing the treatment; the autonomy of decision making in respect to the ratio and number of online and f2f sessions; the necessity of providing training; the need to develop a concept of embedding BT in the health care system and funding the additional effort; and the use of sophisticated technical solutions.

[Internet-based resilience training and prevention of mental disorders]

BACKGROUND

Resilience is associated with a positive and resource-oriented perspective. Therefore, it seems especially attractive for health promotion and prevention. In recent years, interventions to foster resilience have been increasingly developed, which train resilience factors and are mainly conducted in a face to face group format.

OBJECTIVE

The question is raised what potential internet-based interventions (i-interventions) that train resilience factors have for health promotion and prevention.

MATERIAL AND METHODS

Based on a narrative overview, the possibilities for i‑interventions that train resilience factors for health promotion and prevention are investigated and the state of research is described.

RESULTS

The effects of the i‑interventions presented here, which aim at fostering resilience, on measures of mental health and well-being are heterogeneous and vary between low to high effects. Stronger evidence for the efficacy of these measures exists for more general i‑interventions that also train resilience factors but are conceptualized for the prevention of specific disorders, such as depression or for stress reduction.

DISCUSSION

Given the heterogeneous nature of intervention contents, theoretical foundations and therapeutic methods used, the heterogeneity of the evidence is discussed. In addition, perspectives for the further development of resource-oriented resilience interventions are outlined.

Internetbasierte Therapie in der Versorgung von Patienten mit depressiven Störungen: Ein Überblick

Zusammenfassung. Internet- und mobilbasierten Interventionen wird großes Potenzial in der Behandlung von Menschen mit depressiver Symptomatik zugeschrieben. Diese Einschätzung hat sich in den letzten Jahren vor dem Hintergrund mehrerer Programmentwicklungen und einer Vielzahl von Studien zur Wirksamkeitsprüfung der zumeist auf der kognitiven Verhaltenstherapie basierten Angebote etabliert. Ziel der vorliegenden Übersichtsarbeit ist es, zu prüfen, inwieweit sich aus der empirischen Befundlage wissenschaftlich fundierte Empfehlungen für die Versorgungsbereiche Prävention, Primärversorgung, ambulante Psychotherapie, fachärztliche Versorgung sowie die stationäre Behandlung ableiten lassen. Hierfür werden die Ergebnisse ausgewählter Studien, die in den genannten Versorgungsbereichen angesiedelt sind und die Erhebung der Diagnose depressive Störung auf ein Expertenurteil stützen, kritisch bewertet. In der Schlussfolgerung ermöglicht die gegenwärtige Studienlage keine eindeutige Empfehlung zum Einsatz von internetbasierten Behandlungsprogrammen in den genannten Versorgungsbereichen.

Preferences for Depression Treatment Including Internet-Based Interventions: Results From a Large Sample of Primary Care Patients

Background: To date, little is known about treatment preferences for depression concerning new media. This study aims to (1) investigate treatment preferences for depression including internet-based interventions and (2) examine subgroup differences concerning age, gender and severity of depression as well as patient-related factors associated with treatment preferences. Methods: Data were derived from the baseline assessment of the @ktiv-trial. Depression treatment preferences were assessed from n = 641 primary care patients with mild to moderate depression regarding the following treatments: medication, psychotherapy, combined treatment, alternative treatment, talking to friends and family, exercise, self-help literature, and internet-based interventions. Depression severity was specified by GPs according to ICD-10 criteria. Ordinal logistic regression models were conducted to identify associated factors of treatment preferences. Results: Patients had a mean age of 43.9 years (SD = 13.8) and more than two thirds (68.6%) were female. About 43% of patients had mild depression while 57% were diagnosed with moderate depression. The majority of patients reported strong preferences for psychotherapy, talking to friends and family, and exercise. About one in five patients was very likely to consider internet-based interventions in case of depression. Younger patients expressed significantly stronger treatment preferences for psychotherapy and internet-based interventions than older patients. The most salient factors associated with treatment preferences were the patients' education and perceived self-efficacy. Conclusions: Patients with depression report individually different treatment preferences.Our results underline the importance of shared decision-making within primary care. Future studies should investigate treatment preferences for different types of internet-based interventions.

Acceptance and barriers to access of occupational e-mental health: cross-sectional findings from a health-risk population of employees

PURPOSE

Occupational e-mental-health (OEMH) may extend existing instruments for preservation or restoration of health and work ability. As a key precondition to efficient implementation, this study examined acceptance and person-centered barriers to potential uptake of OEMH for work-related distress in employees with an elevated risk of early retirement.

METHODS

Within the framework of the "Third German Sociomedical Panel of Employees", 1829 employees with prior sickness absence payments filled out a self-administered questionnaire. Participants had a mean age of 49.93 years (SD = 4.06). 6.2% indicated prior use of eHealth interventions. Potential predictors of acceptance of OEMH were examined based on the "Unified Theory of Acceptance and Use of Technology" (UTAUT) extended by work ability, mental health, eHealth literacy and demographic characteristics.

RESULTS

89.1% (n = 1579) showed low to moderate acceptance (M = 2.20, SD = 1.05, range 1-5). A path analysis revealed significant, positive direct effects of UTAUT predictors on acceptance (performance expectancy: 0.48, SE = 0.02, p < 0.001; effort expectancy: 0.20, SE = 0.02, p < 0.001; social influence: 0.28, SE = 0.02, p < 0.001).Online time and frequency of online health information search were further positive direct predictors of acceptance. Model fit was good [χ ²(7) = 12.91, p = 0.07, RMSEA = 0.02, CFI = 1.00, TLI = 0.99, SRMR = 0.01].

CONCLUSIONS

Attitudes towards OEMH are rather disadvantageous in the studied risk group. Implementation of OEMH, therefore, requires a-priori education including promotion of awareness, favorable attitudes regarding efficacy and usability in a collaborative approach.

Ready for eHealth? Health Professionals' Acceptance and Adoption of eHealth Interventions in Inpatient Routine Care

eHealth interventions can be effective in treating health problems. However, adoption in inpatient routine care seems limited. The present study therefore aimed to investigate barriers and facilitators to acceptance of eHealth interventions and of online aftercare in particular in health professionals of inpatient treatment. A total of 152 out of 287 health professionals of various professional groups in four inpatient rehabilitation facilities filled out a self-administered web-based questionnaire (response rate: 53%); 128 individuals were eligible for further data analysis. Acceptance and possible predictors were investigated with a complex research model based on the Unified Theory of Acceptance and Use of Technology. Acceptance of eHealth interventions was rather low (M = 2.47, SD = 0.98); however, acceptance of online aftercare was moderate (M = 3.08, SD = 0.96, t(127) = 8.22, p < .001), and eHealth literacy was elevated. Social influence, performance expectancy, and treatment-related internet and mobile use significantly predicted overall acceptance. No differences were found between professional and age groups. Although acceptance of eHealth interventions was limited in health professionals of inpatient treatment, moderate acceptance of online aftercare for work-related stress implies a basis for future implementation. Tailored eHealth education addressing misconceptions about inferiority and incongruity with conventional treatment considering the systemic aspect of acceptance formation are needed.