Patient Perspectives on Strengths and Challenges of Therapist-Assisted Internet-Delivered Cognitive Behaviour Therapy: Using the Patient Voice to Improve Care

Perceptions of client stories in internet-delivered cognitive behaviour therapy: A mixed-methods evaluation

Internet-delivered Cognitive-Behavioural Therapy (ICBT) aims to support people with mental health concerns using online treatment materials. Client stories (either real or a composite based on many clients) are often used in ICBT to facilitate learning. However, these stories remain understudied in terms of how they are perceived by clients, as well as their relationship to ICBT engagement, satisfaction, and outcomes. Among a sample of 324 clients enrolled in transdiagnostic ICBT targeting symptoms of depression and anxiety, we examined client perceptions of stories through mixed-method qualitative (open-ended) and quantitative (closed-ended) data collection. Specifically, 234 (72.22 %) clients responded to questions about stories at 4 weeks and 221 (68.21 %) responded to questions at 8 weeks. Most clients who responded to questions endorsed reviewing at least some stories (79.06 % at 4 weeks, 71.95 % at 8 weeks). Moreover, they rated stories positively in terms of being relatable, making clients feel less alone, increasing knowledge, providing ideas for how to use skills, and motivating clients to use skills. These perceptions of stories remained stable over the course of treatment. Stories were perceived more positively among those with lower symptom severity at 8 weeks as well as those who were more satisfied with ICBT at 8 weeks. Story perceptions at 4 weeks were predictive of decreased post-treatment anxiety symptom severity but not depression while controlling for baseline scores, age, and education. 26.49 % of clients at 4 weeks who reviewed stories and 33.33 % at 8 weeks provided suggestions about how to improve stories. In a qualitative analysis, we found 5 categories of suggestions including increasing the variety of issues and relatability of stories, ensuring the stories are realistic, refining the formatting, and making the stories shorter. Overall, this study provides insights into how client stories could be improved to play a more significant role in future ICBT programs.

Increasing the accessibility to internet-based cognitive behavioural therapy for depression: A single-blind randomized controlled trial of condensed versus full-text versions

Background

Research shows that internet-based cognitive behavioural therapy (iCBT) is an effective treatment for depression. However, little is known about how the length of the text material in iCBT affects outcomes.

Objective

The aim of this study was to test whether a condensed iCBT version for depression would be non-inferior to the existing full-text version in reducing depressive symptoms at post-treatment. We also wanted to test non-inferiority for secondary outcomes and explore reading speed and ADHD symptoms as potential moderators.

Method

A single-blind randomized controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; full-text (around 60,000 words) and condensed (around 30,000 words, with the option to listen to the text). Estimated between-group effect sizes and their confidence intervals for depression, anxiety and quality of life, were compared to a pre-determined non-inferiority margin (ES = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted.

Results

The condensed version of iCBT was non-inferior to the full-text version on post-treatment measures for depressive symptoms (95 % CI = -0.42-0.24), anxiety symptoms (95 % CI = -0.24-0.32), and quality of life (95 % CI = -0.09-0.49). Non-inferiority was inconclusive for depressive symptoms at the one-year follow-up (95 % CI = -0.60-0.47). There was no significant moderation effects of reading speed (p = 0.06) or ADHD symptoms (p = 0.11) on depressive symptoms.

Conclusion

These results indicate that a condensed version of iCBT for depression is as effective at treating depression as the full-text version. By shortening texts, iCBT may be made available to more people. Due to unequal dropout rates between the groups, these results are preliminary and need to be replicated.

Internet-Delivered Cognitive Behavioral Therapy Tailored to Spouses and Significant Others of Public Safety Personnel: Formative Evaluation Study

BACKGROUND

Spouses and significant others (SSOs) of public safety personnel (PSP) are affected by the risks and requirements of these occupations. Internet-delivered cognitive behavioral therapy (ICBT) provides a convenient and accessible treatment format that can be tailored to the needs of SSOs of PSP.

OBJECTIVE

This study aimed to assess the initial use and client perceptions (eg, likes, helpfulness, and areas for improvement) of a self-guided, transdiagnostic ICBT course designed for Canadian SSOs of PSP and identify opportunities to further tailor ICBT for this group.

METHODS

SSOs were invited to complete a 5-lesson, self-guided, transdiagnostic ICBT course. Descriptive statistics were used to analyze the demographic and clinical characteristics of participants. Content analysis was used to analyze the data from open-ended survey responses and interviews to understand their experiences with ICBT.

RESULTS

Clients (N=118) endorsed various mental health concerns (eg, depression, anxiety, posttraumatic stress symptoms, and relationship concerns) with a range of severity levels. Most clients identified as White (110/116, 94.8%) and women (108/116, 91.5%), with a mean age of 42.03 (SD 9.36) years. Of the 26 clients who were interviewed, 89% (23/26) reported believing that ICBT is helpful and 92% (24/26) reported finding at least 1 skill helpful. Clients provided suggestions for course improvements. On the basis of this feedback and quantitative data, changes were made to areas such as the delivery of materials, content, case stories, and timelines. Overall, the results indicated that many SSOs of PSP had positive perceptions of ICBT tailored to their needs and found several aspects of the course helpful, supporting the continued delivery of tailored ICBT to this population. However, there remains a need for continued promotion of the course and outreach to diverse groups of SSOs of PSP.

CONCLUSIONS

Findings from this formative evaluation provide insight into the unique experiences and needs of SSOs of PSP and provide preliminary evidence for the use of tailored ICBT to support the mental health of this group in Canada.

Patient-Oriented Research to Improve Internet-Delivered Cognitive Behavioural Therapy for People of Diverse Ethnocultural Groups in Routine Practice

There has been limited research on improving Internet-delivered Cognitive Behavioural Therapy (ICBT) in routine online therapy clinics that serve people from diverse ethnocultural groups (PDEGs). This article describes a patient-oriented adaptation approach used to address this gap in research. A working group consisting of people with lived experience, community representatives, ICBT clinicians, managers, and researchers was formed. The working group examined archival feedback on ICBT from past patients who self-identified as being from diverse ethnocultural backgrounds (N = 278) and the results of interviews with current patients (N = 16), community representatives (N = 6), and clinicians (N = 3). The archival data and interviews revealed the majority of the patients reported being satisfied with and benefitting from ICBT. Suggestions for improvement were not related to the cognitive-behavioural model and techniques, but rather to making treatment materials more inclusive. Consequently, the ICBT adaptation focused on adding content related to cultural influences on mental health, addressing stigma, diversifying case stories, examples, and imagery, adding audiovisual introductions, and replacing English idioms with more descriptive language. Moreover, further training was offered to clinicians, and efforts were made to improve community outreach. This study demonstrates a process for using patient-oriented research to improve ICBT within routine care serving patients of diverse backgrounds.

Efficacy of an Online Workplace Mental Health Accommodations Psychoeducational Course: A Randomized Controlled Trial

Workplace accommodations can improve work functioning for employees with mental health concerns, yet few employees receive accommodations. The current study examined the benefits of providing education on workplace accommodations. In total, 89 participants with symptoms of depression and/or anxiety were randomized to an online psychoeducation course or wait-list control (WLC). The course provided education on symptoms, accommodations, tips for requesting accommodations and making disclosures, and coping strategies. Primary outcomes included the impact of the course on requesting and receiving accommodations, accommodation knowledge, self-stigma, and workplace relationships at 8 weeks post-randomization. Additional analyses examined the impact of the course on symptoms, absenteeism, presenteeism, and self-efficacy and whether supervisory leadership and organizational inclusivity impact disclosure and accommodation use. Participants in the course reported improvements in accommodation knowledge, self-efficacy, and presenteeism compared to the WLC. Both groups reported reduced self-stigma and increased disclosures over time. Specifically, partial disclosures were associated with supportive organizations and supervisors. No group differences were found on accommodation use, symptoms, workplace relationships, or comfort with disclosure. Few participants made accommodation requests, therefore a statistical analysis on requesting or receiving accommodations was not performed. Overall, providing psychoeducation has the potential to assist individuals with depression and anxiety who may require workplace accommodations, but further research is required.

What I missed from my online therapist: A survey-based qualitative investigation of patient experiences of therapist contact in guided internet interventions

Background

The effectiveness of internet-delivered cognitive behavioral therapy (ICBT) in alleviating symptoms of psychological disorders has been demonstrated across qualitative and quantitative studies. Generally, guided ICBT is considered more effective than unguided ICBT. Yet, what therapist contact and guidance specifically add to the treatment is less clear. There is a need for more knowledge about how patients experience the relationship with their therapist in guided ICBT. The aim of the study was to explore what patients missed in the contact with their therapist in guided ICBT in routine care.

Methods

The study used a qualitative design to explore patients´ experiences of the therapist contact in guided ICBT for social anxiety disorder, panic disorder and major depressive disorder. Following treatment, 579 patients received a survey with the open-ended question "What did you miss in the contact with your therapist?" The responses were explored thematically using qualitative content analysis.

Results

A total of 608 unique responses were provided. Of these, 219 responses gave voice to some degree of perceived lack or limitation in their interaction with the therapist or the treatment in general. The analysis yielded three main categories: The first theme, Therapist-ascribed shortcomings, concerned experiences of something missing or lacking in the contact with the ICBT therapist. More specifically, the patients expressed a need for more emotionally attuned and tailored interaction. The second theme was Program obstacles, encompassing expressed wishes for increased therapist responsivity and more contact face-to-face. Self-attributed limitations, the third category, concerned patient experiences of barriers to treatment engagement as originating in themselves.

Conclusion

This study sheds light on what patients receiving guided ICBT in routine care missed in the contact with their therapist. The patients who expressed that something was missing in the contact with their therapist constituted a small part of the responses in the sample, even after being directly asked. The themes that emerged point to significant experiences of being inadequately related and responded to, both with potential adverse consequences for the treatment. These findings give new insights to the role of the guidance in ICBT and have implications for the training and supervision of guided ICBT therapists.

Cost-effectiveness of varying degrees and models of therapist-assisted transdiagnostic internet-delivered cognitive behaviour therapy: Evidence from a randomized controlled trial

In routine care, Internet-delivered Cognitive Behaviour Therapy (ICBT) is often delivered with therapist support via emails/phone calls, but the cost-effectiveness of varying amounts of therapist support or having therapists specialized in ICBT is not known. This study compared the cost-effectiveness of specialized therapists providing ICBT support once-weekly (1WS) versus providing support once-weekly supplemented with a one-business-day response to patient emails (1W/1BD-S). We further compared the cost-effectiveness of 1W support offered by therapists employed in a specialized clinic (1WS) versus community clinics where therapists primarily deliver face-to-face therapy (1WC). Patients were randomly allocated to groups: 1WS group (n = 216), 1W/1BD-S group (n = 233), and 1WC group (n = 226). At baseline, 12, 24 and 52-week follow-up, patients completed the Treatment Inventory of Costs in Patients with Psychiatric Disorders questionnaire (TiC-P) adapted for use in Canada to assess healthcare use and productivity losses. Additionally, to assess Quality Adjusted Life Years (QALYs) gained, patients completed the EQ-5D-5L at the same time periods. We quantified uncertainties by one-way and probabilistic sensitivity analysis and reported Incremental cost-effectiveness ratios (ICER), cost-effectiveness planes and acceptability curves. Cost-effectiveness over 52 weeks was CAD 3072/QALY for 1WC, CAD 3244/QALY for 1W/1BD-S, and CAD 3528/QALY for 1WS. Our model suggests that 1WS is the best strategy since the incremental cost per QALY is below the $50,000 threshold (ICER is CAD 42,328/QALY compared to the next most effective, 1WC). 1W/1BD-S is dominated by the other strategies. The cost-effectiveness acceptability curves suggest that the 1WS group has a higher probability for cost-effectiveness (38 %) than 1W/1BD-S (30 %) and 1WC (32 %) when the willingness to pay is $50,000 per QALY. These results have important implications for health policymakers deciding on delivery of ICBT for the treatment of anxiety and/depressive disorders.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Development of a Digital Support Application With Evidence-Based Content for Sustainable Return to Work for Persons With Chronic Pain and Their Employers: User-Centered Agile Design Approach

BACKGROUND

Persons with chronic pain experience a lack of support after completing rehabilitation and the responsibility for the return-to-work (RTW) process is taken over by the employer. In addition, employers describe not knowing how to support their employees. Smartphone apps have been increasingly used for self-management, but there is a lack of available eHealth apps with evidence-based content providing digital support for persons with chronic pain and their employers when they return to work.

OBJECTIVE

This study aims to describe the development of a digital support application with evidence-based content that includes a biopsychosocial perspective on chronic pain for sustainable RTW for persons with chronic pain and their employers (SWEPPE [Sustainable Worker Digital Support for Persons With Chronic Pain and Their Employers]).

METHODS

A user-centered agile design approach was applied. The multidisciplinary project team consisted of health care researchers, a user representative, and a software team. A total of 2 reference groups of 7 persons with chronic pain and 4 employers participated in the development process and usability testing. Mixed methods were used for data collection. The design was revised using feedback from the reference groups. The content of SWEPPE was developed based on existing evidence and input from the reference groups.

RESULTS

The reference groups identified the following as important characteristics to include in SWEPPE: keeping users motivated, tracking health status and work situation, and following progress. SWEPPE was developed as a smartphone app for the persons with chronic pain and as a web application for their employers. SWEPPE consists of six modules: the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer. The employers found the following functions in SWEPPE to be the most useful: employees' goals related to RTW, barriers to RTW, support wanted from the employer, and the ability to follow employees' progress. The persons with chronic pain found the following functions in SWEPPE to be the most useful: setting a goal related to RTW, identifying barriers and strategies, and self-monitoring. Usability testing revealed that SWEPPE was safe, useful (ie, provided relevant information), logical, and easy to use with an appealing interface.

CONCLUSIONS

This study reports the development of a digital support application for persons with chronic pain and their employers. SWEPPE fulfilled the need of support after an interdisciplinary pain rehabilitation program with useful functions such as setting a goal related to RTW, identification of barriers and strategies for RTW, self-monitoring, and sharing information between the employee and the employer. The user-centered agile design approach contributed to creating SWEPPE as a relevant and easy-to-use eHealth intervention. Further studies are needed to examine the effectiveness of SWEPPE in a clinical setting.

A randomized factorial trial of internet-delivered cognitive behavioural therapy: An 8-week program with or without extended support and booster lesson

While internet-delivered cognitive behavioural therapy (ICBT) is effective, some patients suggest extended support post-treatment could improve care. In this randomized factorial trial, we examined the benefits of an 8-week therapist-assisted ICBT program offered with or without an optional 4-week extension of support (Factor 1) and with or without an optional booster lesson (Factor 2). Patients screened for ICBT for depression and/or anxiety were randomly assigned to the conditions (N = 434) and we examined the use of the extension and booster, differences between those who did or did not use extension or booster, and the impact of the extension or booster on outcomes, engagement, and satisfaction at 26-weeks post-enrollment. Therapists recorded time and observations with offering support during the extension and booster. In the extension group, 54.4% (n = 56) requested the extension, while in the booster group 50.9% (n = 56) accessed the booster, and in the combined group, 41.6% (n = 47) requested the extension and 51.3% (n = 58) accessed the booster. Those who requested the extension were older, and more likely to report medication and mental health service use and severe mental health-related disability at pre-treatment; they also reported putting less effort into ICBT and finding skills more difficult. The booster was more often used among those with lower symptom severity, and those who put more effort into and had more positive experiences with ICBT. As expected, those assigned to extension sent more messages to their therapist, and those assigned to booster logged in more often. Therapists also took more time to deliver ICBT with an extension (>18 min) or booster (>13 min) compared to the 8-week program, and perceived extension and booster as beneficial for some, but not all patients. Treatment satisfaction was high across conditions, and effect sizes were large from pre-treatment to 26-week follow-up on most measures. No significant group differences were found in this study. Lack of group differences, however, could reflect low use of the extension and booster. Results provide helpful information about the demand for extensions and boosters, and provide directions for future research.

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

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

Improving internet-delivered cognitive behaviour therapy for alcohol misuse: Patient perspectives following program completion

Although Internet-delivered cognitive behaviour therapy (ICBT) for alcohol misuse is efficacious in research trials, it is not routinely available in practice. Moreover, there is considerable variability in engagement and outcomes of ICBT for alcohol misuse across studies. The Alcohol Change Course (ACC) is an ICBT program that is offered free of charge by an online clinic in Saskatchewan, Canada, which seeks to fill this service gap, while also conducting research to direct future improvements of ICBT. As there is limited qualitative patient-oriented research designed to improve ICBT for alcohol misuse, in this study, we describe patient perceptions of the ACC post-treatment. Specifically, post-treatment feedback was obtained from 191 of 312 patients who enrolled in the ACC. Qualitative thematic analysis was used to examine post-treatment written comments related to what patients liked and disliked about the course, which skills were most helpful for them, and their suggestions for future patients. The majority of patients endorsed being very satisfied or satisfied with the course (n = 133, 69.6%) and 94.2% (n = 180) perceived the course as being worth their time. Worksheets (n = 61, 31.9%) and reflections of others (n = 40, 20.9%) received the most praise. Coping with cravings (n = 63, 33.0%), and identifying and managing risky situations (n = 46, 24.1%) were reported as the most helpful skills. Several suggestions for refining the course were provided with the most frequent recommendation being a desire for increased personal interaction (n = 24, 12.6%) followed by a desire for wanting more information (n = 22, 11.5%). Many patients offered advice for future ACC patients, including suggestions to make a commitment (n = 47, 24.6%), do all of the work (n = 29, 15.2%), and keep a consistent approach to the course (n = 24, 12.6%). The results provide valuable patient-oriented directions for improving ICBT for alcohol misuse.

Insights into internet-delivered cognitive behavioural therapy for public safety personnel: Exploration of client experiences during and after treatment

Canadian public safety personnel (PSP) experience high rates of mental health problems and barriers to receiving care. Internet-delivered cognitive behavioural therapy (ICBT) may help reduce barriers to care; however, there is no literature involving qualitative analyses of client feedback to describe PSP experiences with ICBT. Identifying these experiences is important because it can inform future use of ICBT with this group that has unique needs. The current study was designed to explore how clients (N = 82) experienced ICBT that had been tailored to meet their needs; specifically, the study assessed their perceptions of program impacts, what clients found helpful, and client suggestions for improvements. The ICBT course included five core lessons, client stories, and nine initial additional resources, as well as flexible frequencies (optional, once weekly, or twice weekly) and durations (8 to 16 weeks) of therapist support. A qualitative reliability thematic analysis was used to analyze client communications and feedback. Responses to a Treatment Satisfaction Questionnaire administered at eight weeks post-enrollment were available for 57 clients. Client emails with therapists were also examined among all clients, including an additional 25 clients who did not complete the Treatment Satisfaction Questionnaire. Themes identified in the qualitative analyses were related to: reported impacts and hindering events, helpful and challenging course skills and content, helpful aspects of the course, and areas for improvement. Clients who completed the Treatment Satisfaction Questionnaire and those who did not reported beneficial impacts from the program, with the most commonly endorsed themes being skill development and normalizing mental health issues. Hindering events were experienced by both groups and included timeline challenges, technology challenges, and negative effects. Comments from both groups suggested that clients had more success than challenges when practicing the skills. Thought challenging was the skill most frequently identified as helpful. Clients described many aspects of the program as helpful with the most frequently endorsed themes being the course format and content, the flexible nature of the course, access to additional materials and case stories, and therapist assistance. Clients also provided suggestions for improving the course (e.g., case stories, additional resources, timelines audio and videos). Overall, client communications suggest that ICBT is accepted and perceived as beneficial among PSP. These results informed rapid improvements to the ICBT program tailored for PSP and may inform others seeking to provide digital mental health services to PSP.

A qualitative study of patients’ experiences and acceptance of computerised cognitive behavioural therapy in primary care, Scotland

Computerised cognitive behavioural therapy (CCBT) has been made available within the National Health Service (NHS) across Scotland as an alternative treatment for mild to moderate anxiety and depression. However, the provision of CCBT services is still limited in the NHS, possibly affecting delivery of this computer-aided therapy to patients and inhibiting acceptance and uptake of this intervention. This paper reports on the qualitative exploration of patients’ experiences and acceptance of one CCBT programme delivering computer-assisted therapy (Beating the Blues: BTB), examining particularly the point of referral, access to treatment, and support. Thematic analysis was conducted on semi-structured face-to-face and email interviews with 33 patients at different NHS organisations across Scotland. Data analysis generated six key themes which illustrated patients’ experiences relating to referral and access to the treatment, and the challenges they faced: (1) information dissemination; (2) expectations and the impact of waiting for BTB; (3) impact of locations on experience of BTB; (4) preference for home access; (5) desire for better human support; and (6) desire for additional application support features. The findings highlighted that better methods of implementing and delivering such CCBT services together with the design of the technological interventions are vital to the success of these services.

Key learning aims

(1)

The efficacy of automated feedback after internet-based depression screening: Study protocol of the German, three-armed, randomised controlled trial DISCOVER

BACKGROUND

Depression is one of the most disabling disorders worldwide, yet it often remains undetected. One promising approach to address both early detection and disease burden is depression screening followed by direct feedback to patients. Evidence suggests that individuals often seek information regarding mental health on the internet. Thus, internet-based screening with automated feedback has great potential to address individuals with undetected depression.

OBJECTIVES

To determine whether automated feedback after internet-based depression screening reduces depression severity as compared to no feedback.

METHODS

The internet-based, observer-blinded DISCOVER RCT aims to recruit a total of 1074 individuals. Participants will be screened for depression using the Patient Health Questionnaire (PHQ-9). In case of a positive screening result (PHQ-9 ≥ 10), participants with undetected depression will be randomised into one of three balanced study arms to receive either (a) no feedback (control arm), (b) standard feedback, or (c) tailored feedback on their screening result. The tailored feedback version will be adapted to participants' characteristics, i.e. symptom profile, preferences, and demographic characteristics. The primary hypothesis is that feedback reduces depression severity six months after screening compared to no feedback. The secondary hypothesis is that tailored feedback is more efficacious compared to standard feedback. Further outcomes are depression care, help-seeking behaviour, health-related quality of life, anxiety, somatic symptom severity, intervention acceptance, illness beliefs, adverse events, and a health economic evaluation. Follow-ups will be conducted one month and six months after screening by self-report questionnaires and clinical interviews. According to a statistical analysis plan, the primary outcome will be analysed on an intention-to-treat basis applying multilevel modelling.

DISCUSSION

The results of the DISCOVER RCT will inform about how automated feedback after internet-based screening could improve early detection and resolution of depression. Ways of dissemination and how the trial can contribute to an understanding of help-seeking behaviour processes will be discussed. If the results show that automated feedback after internet-based depression screening can reduce depression severity, the intervention could be easily implemented and might substantially reduce the disease burden of individuals with undetected depression.

ETHICAL APPROVAL

The study is approved by the Ethics Committee of the Hamburg Medical Association.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov in November 2020 (identifier: NCT04633096).

Internet-delivered cognitive processing therapy for individuals with a history of bullying victimization: a randomized controlled trial

The purpose of this randomized controlled trial was to test an internet-delivered version of cognitive processing therapy (CPT) for the psychological distress associated with bullying victimization. The sample comprised 52 adults (i.e. 69.20% women; mean age = 43.37 (SD = 12.47); 3.85% ethnic minority) who self-identified as having a lifetime history of bullying victimization. Participants were randomized into three groups, which received 12 sessions of internet-delivered, therapist-guided, and content-modified version of CPT, 12 sessions of internet-delivered and therapist-guided stress management (SM), or a waitlist. Treatment outcomes included maladaptive trauma appraisals, symptoms of posttraumatic stress disorder (PTSD), depression, general anxiety and stress, social anxiety, and anger. Hierarchical linear modeling was used to analyse the data. Findings indicated that CPT was effective in reducing the strength of maladaptive appraisals related to bullying victimization and symptoms of PTSD compared to the waitlist and SM. SM outperformed CPT and the waitlist in reducing symptoms of depression, general anxiety, and stress. In conclusion, the results of this trial suggest that internet-delivered CPT is effective for the psychological distress and maladaptive appraisals associated with bullying victimization but that adaptions might be needed to target more effectively symptoms of anxiety and depression.

Transdiagnostic Internet-delivered cognitive behaviour therapy with therapist support offered once-weekly or once-weekly supplemented with therapist support within one-business-day: Pragmatic randomized controlled trial

In routine care, internet-delivered cognitive behaviour therapy (iCBT) regularly includes therapist support delivered via secure email, but the optimal response time to emails is unknown. In this study, we compared the benefits of therapists providing support once-weekly versus therapists providing support once-weekly supplemented with a one-business-day response to all patient emails. This pragmatic randomized controlled trial included therapists employed by a specialized iCBT clinic or community mental health clinics, where providing iCBT is a secondary service. Patients with depression and/or anxiety who enrolled in transdiagnostic iCBT (5 core lessons over 8 weeks) were randomized to: 1) once-weekly support supplemented with a one-business-day response to patient emails by specialized therapists (n = 233); 2) once-weekly support also offered by specialized therapists (n = 216); or 3) once-weekly support offered by community clinic therapists (n = 226). Outcomes were measured at 8, 12, 24, and 52-weeks post-enrollment. Patient engagement and treatment experiences (e.g., treatment satisfaction, therapist alliance) were also assessed and a focus group was conducted with therapists. Supplementing once-weekly therapist support with a one-business-day response to patient emails resulted in therapists sending more emails to patients (M: 13 versus 9) and required more therapist time over treatment (M: 155 versus 109 min), but was not associated with improved outcomes, patient engagement or treatment experiences. All groups showed large improvements in symptoms of depression and anxiety maintained at 52-week follow-up, strong engagement and positive treatment experiences. Therapists viewed challenges of responding to patient emails within one-business-day to outweigh benefits. Contrary to expectations, supplementing once-weekly therapist support with a one-business-day response to all patient emails did not benefit patients and increased therapist time as well as therapist challenges when delivering iCBT in routine care.

A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients (n = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care.

Managing work participation for people with rheumatic and musculoskeletal diseases

Improving work participation for individuals with rheumatic and musculoskeletal diseases (RMDs), has gained increasing interest over the last 10 years. New approaches are based upon increasing adoption of a biopsychosocial approach to improving work participation, incorporating evidence that health professionals within multidisciplinary teams have a key and critical role. In particular, interaction between health professionals and employers, and rehabilitation services that are linked to the workplace are key elements for improving work participation for people with RMDs. This review outlines recent research that underpins approaches for health professionals to develop their role in improving work participation for people with RMDs based on recent research; it outlines how to measure work-related outcomes in clinical practice, models of work participation, and approaches for health professionals to improve work participation outcomes. The potential for developing the role of health professionals in future years is also outlined.

Patient involvement in developing a patient-targeted feedback intervention after depression screening in primary care within the randomized controlled trial GET.FEEDBACK.GP

Background

Patient and public involvement (PPI) is increasingly required in mental health services research. To empower patients to actively address depression, the GET.FEEDBACK.GP study evaluates a patient‐targeted feedback intervention after depression screening using the Patient Health Questionnaire (PHQ‐9).

Objective

To refine the patient‐targeted feedback from a previous study within a participatory research team (PRT) by conducting workshops to investigate patients' needs and preferences for feedback. To evaluate the process and outcome of PPI.

Design

Patient and public involvement was carried out on the levels of collaboration and consultation. A PRT of patient partners and researchers planned and conducted three workshops with patients. Patients' needs were investigated using a focus group. Participants prioritized needs, discussed feedback drafts and evaluated two drafts using cognitive debriefings. Researchers of the PRT communicated the results at project level. PPI was evaluated using the Public and Patient Engagement Evaluation Tools (PPEET).

Setting and Participants

A purposeful sampling of N = 12 patients with experiences of depression participated in at least one workshop.

Results

Relevant content‐related needs about feedback (eg no distinction between severe and moderate symptoms), recommendations for action and patient‐relevant information were considered. Needs for comprehensible, valuing, nonstigmatizing language and design elements (eg dimensional bar) were implemented. Workshops and PRT were positively evaluated.

Discussion and Conclusions

Patient and public involvement influenced the content, wording and design of the feedback. Strengths include two levels of PPI, methodical diversity and purposeful sampling. Limitations include the lack of inclusion of patients who are unaware of their depression. The evaluated PPI concept can be useful for future studies.

From Research to Practice: Ten Lessons in Delivering Digital Mental Health Services

There is a large body of research showing that psychological treatment can be effectively delivered via the internet, and Digital Mental Health Services (DMHS) are now delivering those interventions in routine care. However, not all attempts to translate these research outcomes into routine care have been successful. This paper draws on the experience of successful DMHS in Australia and Canada to describe ten lessons learned while establishing and delivering internet-delivered cognitive behavioural therapy (ICBT) and other mental health services as part of routine care. These lessons include learnings at four levels of analysis, including lessons learned working with (1) consumers, (2) therapists, (3) when operating DMHS, and (4) working within healthcare systems. Key themes include recognising that DMHS should provide not only treatment but also information and assessment services, that DMHS require robust systems for training and supervising therapists, that specialist skills are required to operate DMHS, and that the outcome data from DMHS can inform future mental health policy. We also confirm that operating such clinics is particularly challenging in the evolving funding, policy, and regulatory context, as well as increasing expectations from consumers about DMHS. Notwithstanding the difficulties of delivering DMHS, we conclude that the benefits of such services for the broader community significantly outweigh the challenges.