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

Effectiveness of Blended Internet-based Self-help and Face-to-face Intervention for Depression: A Pilot Study from India

Background

Depression is a common mental health disorder with a wide treatment gap despite the availability of a number of effective treatment options. Blended interventions adopt a novel approach in combining internet-based self-help with brief face-to-face sessions thereby combining the advantages of both approaches and offering scope to address the treatment gap. The present study examined the effectiveness of a blended intervention combining the use of guided internet-based self-help with four to six face-to-face sessions in the treatment of mild to moderate depression.

Method

A single group, open-label design was adopted with baseline, postintervention, and three-month follow-up assessments. The sample comprised 60 individuals with a primary diagnosis of major depressive disorder, dysthymia, or recurrent depressive disorder of mild or moderate severity meeting eligibility criteria. Standardized measures (self-report and clinician-rated) were used to examine the effectiveness of the intervention in reducing depression, improving functioning, self-esteem, and psychological recovery. A total of 40 participants completed the intervention and follow-up assessments.

Results

Significant improvements were noted from baseline to post-assessment for both completers' and intent-to-treat samples, with medium to large effect size on most outcome measures and maintenance of gains at follow-up. Eighty-five percent of the completers showed clinically significant improvement. Subgroups of blended intervention participants with and without pharmacotherapy showed similar outcomes. Completers were higher on interest in learning self-help skills and on the Growth subscale of psychological recovery, compared to the dropouts at baseline.

Conclusion

The blended intervention demonstrated effectiveness in reducing depression and improving self-esteem, and functional and psychological recovery.

An implementation facilitation intervention to improve the musculoskeletal X-ray reporting by radiographers across London

BACKGROUND

The National Healthcare Service (NHS) radiology service delivery in London is representative of the current pressures and challenges faced in England of Musculoskeletal (MSK) X-ray reporting workforce shortages, and national turnaround time (TATs) targets. The implementation project evaluated facilitation as a strategy to achieve the NHS England 50% target for all MSK X-rays to be reported by radiographers.

METHODS

The project was an eight-month multi-centre (n = 5 London NHS Trusts) study applying the Promoting Action on Research Implementation in Health Services (PARIHS) framework with embedded mixed-methods evaluation. Initial observational data using the Context Assessment Index (CAI) tool and the Workplace Culture Critical Analysis Tool (WCCAT) set the implementation interventions which comprised external facilitation, to support internal facilitators action learning activities. Evaluation data comprised monthly reporting performance, systems mapping, interviews.

RESULTS

System mapping allowed a perspective beyond the characteristics of the NHS Trusts involved (small single site hospitals to large multi-sites hospitals) of mixed clinical duties, scope of practice, reporting session allocation, and equipment used. CAI scores for workplace culture demonstrated x ¯ = 73.7% (SD 6.8; 95%CI 8.49), leadership scored x ¯ = 69.3% (SD 7.3; 95% CI 9.17), and evaluation scored x ¯ = 75.5% (SD 6.9; 95% CI 98.63). WCCAT observations provided themes for facilitation focusing on remote reporting, insourcing backlogs, prioritising worklists to reduce breaching TATs, reporting metrics, and reducing auto reporting. The combined reporting of MSK X-rays by London radiographers during this study achieved x ¯ = 53.7%.

CONCLUSION

This study had an innovative approach using an implementation facilitation framework to improve service delivery. The clinical workplace context in which MSK X-ray reporting by radiographers occurs was key to implementing change. The complexities of sustaining and upscaling MSK X-ray reporting by radiographers to meet the NHS England target of 50% are varied and require local champions to facilitate and drive change at organisational levels. It is recommended that there are dedicated 'resources' to sustain implementations with a community of practice for support. Workplace leadership and stakeholder networks are needed to sustain improved working practices and embrace regular evaluation and monitoring of service delivery performance.

Stakeholder perspectives on implementation of internet-delivered cognitive behaviour therapy in physical medicine rehabilitation setting using the Consolidated Framework for Implementation Research

INTRODUCTION

Despite the growing evidence for the effects of tailored internet-delivered cognitive behaviour therapy (ICBT) programmes for those receiving physical rehabilitation, there is a lack of implementation of these programmes in a clinical or community setting. The aim of the current study was to evaluate barriers and facilitators of implementing an ICBT programme into a physical medicine rehabilitation setting.

METHODS

Stakeholders with expertise in physical medicine rehabilitation were recruited (n = 25) including: 16 clinicians, 4 administrators, 3 persons with lived experience, and 2 care partners. Individual semi-structured interviews were conducted based on the domains of the Consolidated Framework for Implementation Research (CFIR). Transcripts were analysed using a positivist approach, using deductive thematic content analysis. Themes were coded based on the domains of CFIR.

RESULTS

Facilitators for implementation primarily fell under intervention characteristics including relative advantage, strong evidence and quality, and design quality. Perceived barriers for implementation were identified in the inner setting including leadership engagement, culture, and available resources.

CONCLUSIONS

The results from the current study provide insight on the factors that may contribute towards successful implementation of an ICBT programme in a physical medicine setting.

A qualitative analysis of healthcare professionals' experiences with an internet-based emotion regulation intervention added to acute psychiatric inpatient care

BACKGROUND

Healthcare professionals play an important role in successfully implementing digital interventions in routine mental healthcare settings. While a larger body of research has focused on the experiences of mental healthcare professionals with the combination of digital interventions and face-to-face outpatient treatment, comparatively little is known about their experiences with digital interventions combined with inpatient treatment. This is especially true for acute psychiatric inpatient care, where studies on the implementation of digital interventions are more rare. The current study aimed to investigate healthcare professionals' experiences with an internet-based emotion regulation intervention added to acute psychiatric inpatient treatment.

METHODS

Physicians, nurses, psychologists, social workers, and occupational therapists from three acute inpatient wards (n = 20) were interviewed regarding their experiences. A thematic analysis approach was used to analyze the interview data.

RESULTS

The following themes and corresponding subthemes were identified: lack of experience (few or no previous experiences, no expectations, few points of contact), the intervention as a contemporary complement (positive expectations, necessary and contemporary, positive effects on therapeutic work and patients, characteristics of the internet-based program), concerns about fit for acute psychiatric inpatient care (fit for acute psychiatric inpatients, doubts about implementation), the human factor as essential for implementation (the team makes or breaks it, guidance is key, patient characteristics), and requirements for implementation beyond the human factor (integration into existing treatment structure, resources, changes to the internet-based program, timing).

CONCLUSIONS

While healthcare professionals reported few points of contact with the intervention, they saw it as a contemporary complement to acute psychiatric inpatient care with benefits for therapeutic work and patients. The findings further suggest that specific concerns regarding the fit for acute psychiatric inpatient care remain and that human factors such as support from the ward team, human guidance during the intervention and being mindful of specific patient characteristics are considered important for implementation. Moreover, factors such as integration of the intervention into the ward program, resource availability and the timing of the intervention during a patient's individual stay should be considered for successful implementation.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04990674, 04/08/2021.

Resources, support, and integration as potential barriers and facilitators to the implementation of blended therapy in the routine care of inpatients: a qualitative study

While research on blended therapy (BT), i.e. the combination of face-to-face and digital treatment, has grown rapidly, integrating BT into routine practice remains limited, especially in inpatient settings. This study seeks to investigate the potential barriers healthcare providers and patients are confronted with in implementing BT to inpatients. Here, a retrospective, explorative qualitative research design was employed to gain insights into the experiences of healthcare professionals and inpatients in a real-world clinical setting. Specifically, we utilized semi-structured interviews to explore three key aspects: time resources, organizational support, and integration. A total of 11 therapists and 6 patients were interviewed. To our knowledge, this is one of the first studies to examine the implementation of blended therapy in the routine care of inpatients. We found that therapists emphasized several barriers including overwhelming workloads with insufficient time allocated for the work with the digital tools, inadequate time adjustments, a lack of ongoing training, and the necessity for a well-defined concept and setting of how to implement blended therapy. Interestingly, fewer barriers were reported by patients, who viewed the e-mental health platform as a valuable addition to their standard therapy. They also judged guidance and integration by their therapists as satisfactory and appreciated the adaptability offered in managing their workload in a flexible setting.

Exploring Psychotherapists' Attitudes on Internet- and Mobile-Based Interventions in Germany: Thematic Analysis

BACKGROUND

In recent years, internet- and mobile-based interventions (IMIs) have become increasingly relevant in mental health care and have sparked societal debates. Psychotherapists' perspectives are essential for identifying potential opportunities for improvement, facilitating conditions, and barriers to the implementation of these interventions.

OBJECTIVE

This study aims to explore psychotherapists' perspectives on opportunities for improvement, facilitating conditions, and barriers to using IMIs.

METHODS

The study used a qualitative research design, utilizing open-ended items in a cross-sectional survey. A total of 350 psychotherapists were asked to provide their written opinions on various aspects of IMIs. Thematic analysis was conducted to analyze the data and identify core themes.

RESULTS

The analysis revealed 11 core themes related to the use of IMIs, which were categorized into 4 superordinate categories: "Applicability," "Treatment Resources," "Technology," and "Perceived Risks and Barriers." While many psychotherapists viewed IMIs as a valuable support for conventional psychotherapy, they expressed skepticism about using IMIs as a substitute. Several factors were perceived as hindrances to the applicability of IMIs in clinical practice, including technological issues, subjective concerns about potential data protection risks, a lack of individualization due to the manualized nature of most IMIs, and the high time and financial costs for both psychotherapists and patients. They expressed a desire for easily accessible information on evidence and programs to reduce the time and effort required for training and advocated for this information to be integrated into the conceptualization of new IMIs.

CONCLUSIONS

The findings of this study emphasize the importance of considering psychotherapists' attitudes in the development, evaluation, and implementation of IMIs. This study revealed that psychotherapists recognized both the opportunities and risks associated with the use of IMIs, with most agreeing that IMIs serve as a tool to support traditional psychotherapy rather than as a substitute for it. Furthermore, it is essential to involve psychotherapists in discussions about IMIs specifically, as well as in the development of new methodologies in psychotherapy more broadly. Overall, this study can advance the use of IMIs in mental health care and contribute to the ongoing societal debate surrounding these interventions.

Top-funded companies offering digital health interventions for the prevention and treatment of depression: a systematic market analysis

BACKGROUND

Digital innovations can reduce the global burden of depression by facilitating timely and scalable interventions. In recent years, the number of commercial Digital Health Interventions for Depression (DHIDs) has been on the rise. However, there is limited knowledge on their content and underpinning scientific evidence. This study aimed to: (i) identify the top-funded companies offering DHIDs and (ii) provide an overview of their interventions, including scientific evidence, psychotherapeutic approaches and use of novel technologies.

METHODS

A systematic search was conducted using two venture capital databases to identify the top-30 funded companies offering DHIDs. In addition, studies related to the DHIDs' were identified via academic databases and hand-searching. The methodological quality of the publications was evaluated using the Mixed Methods Appraisal Tool.

RESULTS

The top-30 funded companies offering DHIDs received a total funding of 2,592 million USD. Less than half of the companies produced any scientific research associated with their DHIDs, with a total of 83 publications identified. Twenty-five publications were randomised control trials, of which 15 reported moderate-to-large effects in reducing depression symptoms. Regarding novel technologies, few DHIDs incorporated the use of conversational agents or low-burden sensing technologies.

CONCLUSIONS

Funding received by top-funded companies was not related to the amount of scientific evidence provided on their DHIDs. There was a strong variation in the quantity of evidence produced and an overall need for more rigorous effectiveness trials. Few DHIDs used automated approaches such as conversational agents, limiting their scalability.

Blended CBT Intervention vs. a Guided Web-Based Intervention for Postpartum Depression: Results From a Pilot Randomized Controlled Trial

OBJECTIVES

This pilot randomized controlled trial evaluated the acceptability and preliminary effectiveness of a blended cognitive behavioural intervention-combination of a web-based program and sessions with a psychologist (intervention group)-compared to a guided web-based intervention (active control group) for the treatment of postpartum depression.

METHODS

Adult Portuguese women in the postpartum period (up to 12 months) presenting clinically relevant depressive symptoms were considered eligible. Participants were randomly assigned to the intervention group (n = 17) or the control group (n = 17) and completed self-report questionnaires at baseline, post-intervention and at 3-month follow-up.

RESULTS

In both arms, dropout rates were low, and participants considered the treatment acceptable and useful. Mixed ANOVAs revealed a significant reduction in depressive symptoms and improvements in secondary outcomes (anxiety, negative thoughts, emotion regulation, self-compassion and psychological flexibility) from baseline to post-intervention in both groups. No time × group interactions were found. A significant clinical change in depressive symptoms was observed in more than 80% of the participants in both groups. Significant associations were observed among therapeutic alliance and depressive symptoms.

CONCLUSIONS

The results of our study support the acceptability, usability and preliminary effects on postpartum depression of both interventions and highlight the important role of therapist support in blended and guided web-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04441879.

Blended Psychological Therapy for the Treatment of Psychological Disorders in Adult Patients: Systematic Review and Meta-Analysis

BACKGROUND

Blended therapy (BT) combines digital with face-to-face psychological interventions. BT may improve access to treatment, therapy uptake, and adherence. However, research is scarce on the structure of BT models.

OBJECTIVE

We synthesized the literature to describe BT models used for the treatment of psychological disorders in adults. We investigated whether BT structure, content, and ratio affected treatment efficacy, uptake, and adherence. We also conducted meta-analyses to examine treatment efficacy in intervention-control dyads and associations between treatment outcomes versus BT model structure.

METHODS

PsycINFO, CINAHL, Embase, ProQuest, and MEDLINE databases were searched. Eligibility criteria included articles published in English till March 2023 that described digital and face-to-face elements as part of an intervention plan for treating psychological disorders in adult patients. We developed a coding framework to characterize the BT interventions. A meta-analysis was conducted to calculate effect size (ES; Cohen d and 95% CIs) regarding pre- and posttreatment outcomes in depression and anxiety versus BT structure. The review was registered with PROSPERO and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Searches identified 8436 articles, and data were extracted from 29 studies. BT interventions were analyzed and classified according to mode of interaction between digital and face-to-face components (integrated vs sequential), role of the components (core vs supplementary), component delivery (alternate vs case-by-case), and digital materials assignment mode (standardized vs personalized). Most BT interventions (n=24) used a cognitive behavioral therapy approach for anxiety or depression treatment. Mean rates of uptake (91%) and adherence (81%) were reported across individual studies. BT interventions were more effective or noninferior to treatment as usual, with large spread in the data and a moderate to large ES in the treatment of depression (n=9; Cohen d=-1.1, 95% CI -0.6 to -1.6, P<.001, and z score=-4.3). A small, nonsignificant ES was found for anxiety outcomes (n=5; Cohen d=-0.1, 95% CI -0.3 to 0.05, P=.17, and z score=-1.4). Higher ESs were found in blended interventions with supplementary design (depression: n=11, Cohen d=-0.75, 95% CI -0.56 to -0.95; anxiety: n=8, Cohen d=-0.9, 95% CI -0.6 to -1.2); fewer (≤6) face-to-face sessions (depression: n=9, Cohen d=-0.7, 95% CI -0.5 to -0.9; anxiety: n=7, Cohen d=-0.8, 95% CI -0.3 to -1.3); and a lower ratio (≤50%) of face-to-face versus digital sessions (depression: n=5, Cohen d=-0.8, 95% CI -0.6 to -1.1; anxiety: n=4, Cohen d=-0.8, 95% CI 0.006 to -1.6).

CONCLUSIONS

This study confirmed integrated BT models as feasible to deliver. We found BT to be effective in depression treatment, but anxiety treatment results were nonsignificant. Future studies assessing outcomes across different psychological disorders and therapeutic approaches are required.

TRIAL REGISTRATION

PROSPERO CRD42021258977; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258977.

Implementation of an electronic patient portal in routine mental health care of hospitals in Germany - evaluation of attitudes of healthcare providers

BACKGROUND

The use of digital tools such as electronic patient portals in different health care disciplines and settings has been increasing, but the rate of implementation in clinical practice still lags behind expectations. While studies have linked the use of electronic patient portals to positive health outcomes for patients, studies addressing the viewpoints of healthcare providers are rare.

METHODS

We performed an online survey of attitudes of healthcare providers towards an electronic patient portal for mental health hospitals. The portal was developed by five communal providers of mental health care in different regions in Germany. The survey was carried out during the early phase of implementation of the portal.

RESULTS

Twenty project leaders and 37 clinicians from five different mental health hospitals answered the questionnaire (response rate: 45% and 28%). Overall, acceptance of online applications among respondents was high. The healthcare providers mentioned perceived benefits (e.g. accessibility of new patient groups, use of therapy-free periods) as well as a number of technical, structural, organizational and staffing barriers for successful implementation in hospital settings (e.g. workload of healthcare providers and lack of staff, limited digital competences, unstable WLAN).

CONCLUSION

The perceived barriers and facilitators of the implementation of online applications and electronic patient portals in mental health hospitals identified by healthcare providers may be taken into account. Improving commitment of the healthcare providers to implementation and use of digital interventions may help foster digitalisation in mental health hospitals.

Integrating digital and in-person therapy for PTSD: feasibility and acceptability of blended trauma-focused cognitive therapy in routine care

Introduction

Access to evidence-based psychological therapy for posttraumatic stress disorder (PTSD) is limited. Blended Trauma-focused Cognitive Therapy (bTF-CT), merging internet-modules with a few therapy sessions, may be a pathway to enhance treatment access while maintaining the benefits of face-to-face therapy.

Objectives

This study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness of bTF-CT for PTSD in routine care, as well as the feasibility of assessments and data collection.

Method

A single-arm design was adopted. bTF-CT was provided to 17 participants across two psychiatric and one primary care clinic. Assessments were conducted pre, during, post and 6-months following treatment. We assessed feasibility and acceptability via self-report questionnaires, retention, and attrition rates. To estimate preliminary treatment effectiveness the PTSD Symptom Checklist (PCL-5) was used to assess PTSD symptom severity.

Results

Treatment satisfaction was high with a mean score of 28.7 out of 32 on the Client Satisfaction Questionnaire (SD = 3.5). The dropout rate was low, with 88% treatment retention. Program adherence was satisfactory, with scores ranging from 2.13 to 3.13 out of 4 on the internet intervention patient adherence scale. On the PCL-5, 88% made a reliable change, 64% demonstrated a clinically significant change, and the mean change from pre to post was 24 points (d = 2.13). Some negative effects were reported, such as unpleasant memories, feelings, and disrupted sleep, but these were temporary according to symptom scales.

Conclusions

bTF-CT appears to be acceptable, feasible, and potentially effective when delivered in routine care. A large-scale non-inferiority trial to assess effectiveness compared to a gold-standard treatment is warranted.

Clinical Trial Registration

Clinicaltrials.gov, identifier NCT04881643.

Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial

BACKGROUND

Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression.

OBJECTIVE

This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments.

METHODS

We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised-Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables.

RESULTS

Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=-0.12, 95% CI -0.17 to -0.06) and TAU (B=-0.06, 95% CI -0.11 to -0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=-0.030, 95% CI -0.05 to -0.01; P=.005).

CONCLUSIONS

To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-016-1511-1.

TONI - One for all? Participatory development of a transtheoretic and transdiagnostic online intervention for blended care

Background

Internet-based interventions offer a way to meet the high demand for psychological support. However, this setting also has disadvantages, such as the lack of personal contact and the limited ability to respond to crises. Blended care combines Internet-based interventions with face-to-face psychotherapy and merges the benefits of both settings. To ensure the uptake of blended care in routine care, Internet-based interventions need to be suitable for different therapeutic approaches and mental disorders.

Objective

This paper describes the participatory development process of the Internet-based intervention "TONI" using a common therapeutic language and content on various transdiagnostic topics to be integrated into routine outpatient psychotherapy.

Methods

To develop this intervention in a participatory manner, we followed the Integrate, Design, Assess, and Share (IDEAS) framework. In a multilevel development process, we used a combination of interviews, focus groups, and proofreading to optimally tailor online modules to routine outpatient psychotherapy. Building on well-established cognitive-behavioral online content, we included expert interviews with psychodynamic (n = 20) and systemic psychotherapists (n = 9) as well as focus groups with psychotherapists of different approaches (n = 10) and persons with lived experience of mental illness (PWLE; n = 10).

Results

We describe the development process of TONI step-by-step, outlining the specific requirements that therapists from different therapeutic approaches as well as PWLE have and how we implemented them in our intervention. This includes the content and specific exercises in the online modules, aspects of data protection, language, design, and usability.

Conclusion

Internet-based interventions that use a common therapeutic language and address therapeutic principles across different approaches have the potential to advance digitalization in psychotherapy. Involving psychotherapists and PWLE in intervention development may positively impact acceptance and usage in practice. This study shows how participatory intervention development involving both psychotherapists and PWLE can be carried out.

Healthcare providers' perceived acceptability of a warning signs intervention for rural hospital-to-home transitional care: A cross-sectional study

INTRODUCTION

There is a pressing need for transitional care that prepares rural dwelling medical patients to identify and respond to the signs of worsening health conditions. An evidence-based warning signs intervention has the potential to address this need. While the intervention is predominantly delivered by nurses, other healthcare providers may be required to deliver it in rural communities where human health resources are typically limited. Understanding the perspectives of other healthcare providers likely to be involved in delivering the intervention is a necessary first step to avert consequences of low acceptability, such as poor intervention implementation, uptake, and effectiveness. This study examined and compared nurses' and other healthcare providers' perceived acceptability of an evidence-based warning signs intervention proposed for rural transitional care.

METHODS

A cross-sectional design was used. The convenience sample included 45 nurses and 32 other healthcare providers (e.g., physical and occupational therapists, physicians) who self-identified as delivering transitional care to patients in rural Ontario, Canada. In an online survey, participants were presented with a description of the warning signs intervention and completed established measures of intervention acceptability. The measures captured 10 intervention acceptability attributes (effectiveness, appropriateness, risk, convenience, relevance, applicability, usefulness, frequency of current use, likelihood of future use, and confidence in ability to deliver the intervention). Ratings ≥ 2 indicated acceptability. Data analysis included descriptive statistics, independent samples t-tests, as well as effect sizes to quantify the magnitude of any differences in acceptability ratings between nurses and other healthcare providers.

RESULTS

Nurses and other healthcare providers rated all intervention attributes > 2, except the attributes of convenience and frequency of current use. Differences between the two groups were found for only three attributes: nurses' ratings were significantly higher than other healthcare providers on perceived applicability, frequency of current use, and the likelihood of future use of the intervention (all p's < .007; effect sizes .58 - .68, respectively).

DISCUSSION

The results indicate that both participant groups had positive perspectives of the intervention on most of the attributes and suggest that initiatives to enhance the convenience of the intervention's implementation are warranted to support its widespread adoption in rural transitional care. However, the results also suggest that other healthcare providers may be less receptive to the intervention in practice. Future research is needed to explore and mitigate the possible reasons for low ratings on perceived convenience and frequency of current use of the intervention, as well as the between group differences on perceived applicability, frequency of current use, and the likelihood of future use of the intervention.

CONCLUSIONS

The intervention represents a tenable option for rural transitional care in Ontario, Canada, and possibly other jurisdictions emphasizing transitional care.

[Blended care: state of research and possibilities for implementation]

BACKGROUND

Psychotherapy is effective in treating mental disorders; however, not all patients benefit to the same extent and treatment gains are not always maintained. Blended care (BC) has the potential to improve psychotherapeutic care by combining traditional psychotherapy with online contents.

OBJECTIVE

To explore the potential of BC for psychotherapeutic care and investigate its implementation possibilities.

MATERIAL AND METHODS

Presentation of the effectiveness of various BC modalities, attitudes of users and decision-makers, and discussion of recommendations for its implementation.

RESULTS

Indications for the effectiveness of BC in different modalities has been shown in several studies. Both therapists and patients prefer BC over a purely online intervention and want customizable contents; however, it remains unclear for which patients BC is a particularly suitable treatment option.

CONCLUSION

Various combinations of BC have the potential to be an effective and financially viable treatment option. Successful implementation requires better education about BC and the provision of the necessary infrastructure.

A qualitative interview study of patients' attitudes towards and intention to use digital interventions for depressive disorders on prescription

Background

Depressive disorders are an emerging public health topic. Due to their increasing prevalence, patients with depressive disorders suffer from the lack of therapeutic treatment. Digital health interventions may offer an opportunity to bridge waiting times, supplement, or even substitute in-person treatment. Among others, the Unified Theory of Acceptance and Use of Technology (UTAUT) explains that actual technology use is affected by users' behavioural intention. However, patients' perspectives on digital interventions are rarely discussed within the specific context of primary care provided by general practitioners (GP) and need further exploration.

Method

A qualitative study design with semi-structured interviews was used to explore DTx-acceptance of patients with mild or moderate depression (n = 17). The audio-recorded interviews were transcribed verbatim, coded, and thematically analysed by qualitative content analysis.

Results

Patients' performance expectancies reveal that DTx are not perceived as a substitute for face-to-face treatment. Effort expectancies include potential advantages and efforts concerning technical, motivational, and skill-based aspects. Moreover, we identified health status and experience with depressive disorders as other determinants and potential barriers to patients' DTx acceptance: Difficult stages of depression or long-time experience are perceived hurdles for DTx use. GPs' recommendations were just partly relevant for patients and varied according to patients' consultancy preferences. But still, GPs have a crucial role for access due to prescription. GPs' influence on patients' DTx acceptance varies between three situations: (1) pre-use for consultation, (2) pre-use for access and (3) during DTx-use. Further, GPs' guidance could be especially relevant for patients during DTx-use in routine care.

Discussion

The UTAUT-based exploration suggests that acceptance determinants should be considered independently and embedded in personal and situational aspects. DTx require a healthcare professional to prescribe or diagnose the disease, unlike other digital offerings. We identified prescription- and depression-related determinants, exceeding existing theoretical constructs. GPs' guidance can compensate for some barriers to DTx use e.g., by increasing commitment and motivational support to strengthen patients' acceptance.

Conclusion

We argue for a multidimensional integration of acceptance determinants for further development of health technology acceptance research. Future research should specify how DTx can be integrated into routine care to strengthen user acceptance.

[Online Therapy as an Add-on to Psychoanalysis? What Needs for Online Therapy Modules do Psychodynamic Psychotherapists in Private Practice Express for Their Outpatient Work?]

OBJECTIVE

In recent years, psychotherapists have been increasingly confronted with the challenge of meeting treatment needs efficiently with limited time resources and at the same time achieving stable treatment success in the long term. One way to address this is to integrate Internet-based interventions (IBI) into outpatient psychotherapy. While there is a lot of research on IBI based on cognitive-behavioral therapy, little is known about the same for psychodynamic treatment models. Therefore, the question will be answered as to what specific online modules would need to look like that psychodynamic psychotherapists would use in their outpatient practice to support their regular face-to-face therapies.

METHODS

In this study, 20 psychodynamic psychotherapists were asked about their requirements on the content of online modules that could be integrated into outpatient psychotherapy, using semi-structured interviews. The transcribed interviews were analyzed using Mayring's qualitative content analysis.

RESULTS

Results showed that some psychodynamic psychotherapists already use exercises or materials which could be transferred into the online format. In addition, general requirements about online modules emerged, such as an easy handling or a playful character. At the same time, it became clear when and with what kind of patient groups online modules would be integrated into psychodynamic psychotherapy.

DISCUSSION

The interviewed psychodynamic psychotherapists considered it an attractive approach to offer online modules as a supplement to psychotherapy and in a broad spectrum of content. They gave practical advice for the design of possible modules, both on the level of general handling and regarding concrete contents, words, and ideas.

CONCLUSION

The results contributed to the development of online modules for use in routine care, the effectiveness of which will be investigated in a randomized controlled trial in Germany.

Therapists' experiences with providing guided internet-delivered cognitive behavioral therapy for patients with mild and moderate depression: a thematic analysis

Introduction

Guided internet-delivered therapy has shown promising results for patients with mild and moderate depressive disorder, but several challenges with the format have been reported. The aim of this qualitative study was to investigate therapists' experiences providing guided internet-delivered cognitive behavioral therapy for patients with mild and moderate depression.

Material and methods

Twelve therapists were interviewed, and the interviews were analyzed using reflexive thematic analysis.

Results and conclusion

Three themes were created: (1) For the right person, at the right time. This theme is about therapists' experiences appointing patients to the program. It is challenging to predict which patients will benefit from it, and it is not the right option for all patients. (2) It is not like chatting on Facebook. The second theme was about the experiences with demands on clinics, therapists and patients that must be considered. The internet-delivered treatment should not be viewed as a simple treatment option, and the value of having contact with the patients during treatment was emphasized. (3) It is like a railroad, but without the switches. This theme was about the experiences with how the treatment content was conveyed to the patients, how the therapists expressed concerns with the usability of the program and the reported need for more possibilities in tailoring treatment for each patient.

Determinants of psychotherapists' attitudes to online psychotherapy

Introduction

Online psychotherapy is a form of work that is becoming more and more popular. Public health problems, such as COVID-19, forced mental health professionals and patients to incorporate new methodologies such as the use of electronic media and internet to provide follow-up, treatment and also supervision. The aim of this study was to investigate which factors shape the therapists' attitudes toward online psychotherapy during a pandemic taking into account: (1) attitudes toward the COVID-19 pandemic (fear of contagion, pandemic fatigue, etc.), (2) personal characteristics of the psychotherapists (age, gender, feeling of efficacy, anxiety, depression, etc.), and (3) characteristics of the psychotherapeutic practice (guideline procedure, client age group, professional experience, etc).

Materials and methods

Study participants were 177 psychotherapists from four European countries: Poland (n = 48), Germany (n = 44), Sweden (n = 49), and Portugal (n = 36). Data were collected by means of an individual online survey through the original questionnaire and the standardized scales: a modified version of the Attitudes toward Psychological Online Interventions Scale (APOI), Fear of Contagion by COVID-19 Scale (FCS COVID-19), Pandemic Fatigue Scale (PFS), Hospital Anxiety and Depression Scale (HADS), Social Support Questionnaire (F-SozU K-14), and the Sense of Efficiency Test (SET).

Results

Determinants that impacted psychotherapists' attitudes toward online therapy were: COVID-19 belief in prevention-keeping distance and hand disinfection, pandemic behavioral fatigue, previous online therapy experience (including voice call), working with youth and adults. Our study showed that belief in the sense of prevention in the form of taking care of hand disinfection before the session, pandemic behavioral fatigue and experience in working with adults were significant predictors of negative attitudes of therapists toward online psychological interventions. On the other hand, belief in the sense of prevention in the form of keeping distance during the session had a positive effect on general attitudes toward therapy conducted via the internet.

Discussion

The online therapy boom during the COVID-19 pandemic has spawned a powerful tool for psychotherapists. More research in this area and training of psychotherapists are needed for online psychological interventions to become an effective therapy format that is accepted by patients and therapists alike.

The Role of Compassionate Technology in Blended and Digital Mental Health Interventions: Systematic Scoping Review

BACKGROUND

An essential value in mental health care is compassion: awareness of suffering, tolerating difficult feelings in the face of suffering, and acting or being motivated to alleviate suffering. Currently, technologies for mental health care are on the rise and could offer several advantages, such as more options for self-management by clients and more accessible and economically viable care. However, digital mental health interventions (DMHIs) have not been widely implemented in daily practice. Developing and evaluating DMHIs around important mental health care values, such as compassion, could be key for a better integration of technology in the mental health care context.

OBJECTIVE

This systematic scoping review explored the literature for previous instances where technology for mental health care has been linked to compassion or empathy to investigate how DMHIs can support compassion in mental health care.

METHODS

Searches were conducted in the PsycINFO, PubMed, Scopus, and Web of Science databases, and screening by 2 reviewers resulted in 33 included articles. From these articles, we extracted the following data: technology types, goals, target groups, and roles of the technologies in the intervention; study designs; outcome measures; and the extent to which the technologies met a 5-step proposed definition of compassion.

RESULTS

We found 3 main ways in which technology can contribute to compassion in mental health care: by showing compassion to people, by enhancing self-compassion in people, or by facilitating compassion between people. However, none of the included technologies met all 5 elements of compassion nor were they evaluated in terms of compassion.

CONCLUSIONS

We discuss the potential of compassionate technology, its challenges, and the need to evaluate technology for mental health care on compassion. Our findings could contribute to the development of compassionate technology, in which elements of compassion are explicitly embedded in its design, use, and evaluation.

Child and Adolescent Mental Health during the COVID-19 Pandemic: Challenges of Psychiatric Outpatient Clinics

BACKGROUND

Worldwide national surveys show a rising mental health burden among children and adolescents (C&A) during COVID-19. The objective of the current study is to verify the expected rise in visits to psychiatric outpatient clinics of C&A, especially of new patients.

METHODS

a cross-sectional study focusing on visits as recorded in electronic medical records of eight heterogeneous C&A psychiatric outpatient clinics. The assessment was based on visits held from March to December of 2019 (before the pandemic) in comparison to visits held in 2020 (during the pandemic).

RESULTS

The number of visits was similar for both periods. However, in 2020, 17% of the visits used telepsychiatry (N = 9885). Excluding telepsychiatry reveals a monthly decrease in traditional in-person activities between 2020 and 2019 (691.6 ± 370.8 in 2020 vs. 809.1 ± 422.8 in 2019, mean difference = -117.5, t (69) = -4.07, p = 0.0002, Cohen's d = -0.30). Acceptation of new patients declined during 2020, compared to 2019 (50.0 ± 38.2 in 2020 vs. 62.8 ± 42.9 in 2019; Z = -3.12, p = 0.002, r = 0.44). Telepsychiatry was not used for new patients.

CONCLUSIONS

The activity of C&A psychiatric outpatient clinics did not rise but was guarded due to the use of telepsychiatry. The decline in visits of new patients was explained by the lack of use of telepsychiatry for these patients. This calls for expanding the use of telepsychiatry, especially for new patients.

Qualitative analysis of university counselors' online counseling experiences during the COVID-19 pandemic

This study aimed to reflect on counselors' experiences and the adaptation processes in university counseling centers during the COVID-19 pandemic. Accordingly, 15 counselors and psychologists working at different counseling centers were reached and interviewed. Thematic analysis showed that participants had to adapt to changes brought by the pandemic to continue their services. The adaptation of counseling centers to online practices showed differences according to administrative decisions and technical capacities. As a result of the urgent need to continue providing psychological help, participants moved to online practices, which caused professional and social life changes. Participant attitudes to online counseling were mainly positive. Since students had to move back to their family homes during the pandemic, limited confidentiality was the main problem aside from technological glitches in online sessions. Counselors encountered personal and professional challenges as a result of the ongoing counseling sessions and listed the self-care activities they used.

Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary.

OBJECTIVE

This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia.

METHODS

A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit.

RESULTS

In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it.

CONCLUSIONS

The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04686-4.

A blended psychological intervention for postpartum depression: acceptability and preferences in women presenting depressive symptoms

OBJECTIVES

To evaluate the acceptability of and preferences for a blended psychological intervention (combining face-to-face sessions and web-based interventions) for the treatment of postpartum depression among Portuguese women presenting depressive symptoms and to explore the factors associated with its acceptability.

BACKGROUND

Despite its high prevalence and the existence of effective treatment, still few women seek professional help for postpartum depression, demanding for new treatment formats, such as blended interventions.

METHODS

Women (n = 235) presenting postpartum depressive symptoms (EPDS>9) completed an internet survey assessing sociodemographic and clinical information, depressive symptoms, e-health literacy and the acceptability of and preferences for a blended intervention for postpartum depression.

RESULTS

Most of the participants considered a blended intervention for postpartum depression to be useful and would be available to use it. Women reported significantly more advantages than disadvantages in regard to this treatment format. Married women, employed, with younger babies and with less severe depressive symptoms had a higher likelihood of finding a blended intervention useful. Higher educational levels increased the likelihood of being available to obtain a blended treatment. Most participants preferred an equal distribution of content across face-to-face and online sessions. Approximately one-third of the sample preferred a 75% face-to-face/ 25% online proportion. Most of the women preferred a duration of 45-60 minutes for face-to-face sessions and 30-45 minutes for online sessions.

CONCLUSION

Our findings support and inform the development of blended psychological treatments for postpartum depression, according to women's preferences, and highlight the prioritisation of this format according to women's characteristics.

Forensic Psychiatric Outpatients' and Therapists' Perspectives on a Wearable Biocueing App (Sense-IT) as an Addition to Aggression Regulation Therapy: Qualitative Focus Group and Interview Study

BACKGROUND

Given the increased use of smart devices and the advantages of individual behavioral monitoring and assessment over time, wearable sensor-based mobile health apps are expected to become an important part of future (forensic) mental health care. For successful implementation in clinical practice, consideration of barriers and facilitators is of utmost importance.

OBJECTIVE

The aim of this study was to provide insight into the perspectives of both psychiatric outpatients and therapists in a forensic setting on the use and implementation of the Sense-IT biocueing app in aggression regulation therapy.

METHODS

A combination of qualitative methods was used. First, we assessed the perspectives of forensic outpatients on the use of the Sense-IT biocueing app using semistructured interviews. Next, 2 focus groups with forensic therapists were conducted to gain a more in-depth understanding of their perspectives on facilitators of and barriers to implementation.

RESULTS

Forensic outpatients (n=21) and therapists (n=15) showed a primarily positive attitude toward the addition of the biocueing intervention to therapy, with increased interoceptive and emotional awareness as the most frequently mentioned advantage in both groups. In the semistructured interviews, patients mainly reported barriers related to technical or innovation problems (ie, connection and notification issues, perceived inaccuracy of the feedback, and limitations in the ability to personalize settings). In the focus groups with therapists, 92 facilitator and barrier codes were identified and categorized into technical or innovation level (n=13, 14%), individual therapist level (n=28, 30%), individual patient level (n=33, 36%), and environmental and organizational level (n=18, 20%). The predominant barriers were limitations in usability of the app, patients' motivation, and both therapists' and patients' knowledge and skills. Integration into treatment, expertise within the therapists' team, and provision of time and materials were identified as facilitators.

CONCLUSIONS

The chances of successful implementation and continued use of sensor-based mobile health interventions such as the Sense-IT biocueing app can be increased by considering the barriers and facilitators from patients' and therapists' perspectives. Technical or innovation-related barriers such as usability issues should be addressed first. At the therapist level, increasing integration into daily routines and enhancing affinity with the intervention are highly recommended for successful implementation. Future research is expected to be focused on further development and personalization of biocueing interventions considering what works for whom at what time in line with the trend toward personalizing treatment interventions in mental health care.

Patient and Therapist Expectations for a Blended Cognitive Behavioral Therapy Program for Depression: Qualitative Exploratory Study

BACKGROUND

Blended cognitive behavioral therapy (bCBT)-the combination of digital elements and face-to-face psychotherapy-has been proposed to alleviate challenges that patients and therapists face in conventional cognitive behavioral therapy. There is growing evidence that adding digital elements to face-to-face psychotherapy can contribute to better treatment outcomes. However, bCBT programs still show considerable shortcomings, and knowledge on how to improve digital apps using a bCBT protocol is limited.

OBJECTIVE

This study aimed to inductively identify functions and qualities that are expected from a bCBT treatment for depression in the eyes of patients and psychotherapists who were not currently receiving or practicing bCBT treatment.

METHODS

We used a qualitative exploratory study design and conducted 3 focus group interviews (n=6 in each) and 5 semistructured in-depth interviews with therapists as well as 11 individual interviews with patients with a primary diagnosis of depression and currently undergoing cognitive behavioral therapy treatment in Germany. Themes and categories were established inductively from transcribed interview records based on a rigorous coding method.

RESULTS

Both therapists and patients expected a digital app to provide patients with the opportunity to track their mood, work on therapeutic homework activities, easily access an intervention set for harder moments, and efficiently facilitate administrative tasks. The desire to be able to customize bCBT protocols to individual patient circumstances was evident in both patient and therapist interviews. Patients differed with respect to what content and the amount of material the app should focus on as well as the method of recording experiences. Therapists viewed digital apps as potentially aiding in their documentation work outside of sessions. Different attitudes surfaced on the topic of data security, with patients not as concerned as therapists.

CONCLUSIONS

Both patients and therapists had substantially positive attitudes toward the option of an integrated bCBT treatment. Our study presents novel findings on the expectations and attitudes of patients and therapists.

Factors Associated With Intention and Use of e-Mental Health by Mental Health Counselors in General Practices: Web-Based Survey

BACKGROUND

Mental health care counselors have a high intention to use e-mental health (EMH), whereas actual use is limited. Facilitating future use requires insight into underlying factors as well as eligibility criteria that mental health care counselors use in their decision to apply EMH.

OBJECTIVE

The aim of this study was to unfold the intention and underlying reasons for mental health counselors to use EMH and to unveil the criteria they use to estimate patient eligibility for EMH. The theoretical framework was based on the reasoned action approach model, the Unified Theory of Acceptance and Use of Technology, and the Measurement Instrument for Determinants of Innovation model.

METHODS

To empirically validate our theoretical model, a web-based survey was conducted among mental health care counselors (n=132). To unveil the eligibility criteria, participants were asked to rank their reasons for considering EMH suitable or unsuitable for a patient.

RESULTS

The mean intention to use EMH was positive (mean 4.04, SD 0.64). The mean use of EMH before the COVID-19 pandemic was 38% (mean 0.38, SD 0.22), and it was 49% (mean 0.49, SD 0.25) during the pandemic. In total, 57% of the patient population was considered eligible for EMH. Usefulness and benefits (β=.440; P<.001), Task perception (β=.306; P=.001), and Accessibility (β=.140; P=.02) explained the intention to use EMH (F_3,131=54.151; P<.001; R²=0.559). In turn, intention explained patient eligibility (F_1,130=34.716; P<.001; R²=0.211), whereas intention and patient eligibility explained EMH use (F_2,129=41.047; P<.001; R²=0.389). Patient eligibility partially mediated the relationship between intention to use EMH and EMH use, with a larger direct effect (c'=0.116; P<.001) than indirect effect (c=0.065, 95% CI 0.035-0.099; P<.001). Mental health counselors assessed patients' eligibility for EMH mainly through the availability of computers and the internet and patient motivation.

CONCLUSIONS

To stimulate the use of EMH, intention and patient eligibility need to be influenced. Intention, in turn, can be enhanced by addressing the perceived usefulness and benefits of EMH, perceived accessibility, and task perception. Access to a computer and patients' motivation to use EMH are important in facilitating patient eligibility. To cause an impact with EMH in general practice, mental health counselors need to be convinced of the benefits of EMH and transfer this enthusiasm to the patient. It is recommended to involve mental health counselors in the development of EMH to increase the (perceived) added value and use.

E-mental health implementation in inpatient care: Exploring its potential and future challenges

Background

There is a great evidence base today for the effectiveness of e-mental health, or the use of technology in mental healthcare. However, large-scale implementation in mental healthcare organisations is lacking, especially in inpatient specialized mental healthcare settings.

Aim

The current study aimed to gain insights into the factors that promote or hinder the implementation of e-mental health applications on organisational, professional and patient levels in Belgium.

Methods

Four Belgian psychiatric hospitals and psychiatric departments of general hospitals invited their professionals and patients to use Moodbuster, which is a modular web-based platform with a connected smartphone application for monitoring. The platform was used in addition to treatment as usual for three to four months. The professionals and patients completed pre- and post-implementation questionnaires on their reasons to participate or to decline participation and experiences with the Moodbuster platform.

Results

Main reasons for the organisations to participate in the implementation study were a general interest in e-mental health and seeing it is a helpful add-on to regular treatment. The actual use of Moodbuster by professionals and patients proved to be challenging with only 10 professionals and 24 patients participating. Implementation was hindered by technical difficulties and inpatient care specific factors such as lack of structural facilities to use e-mental health and patient-specific factors. Professionals saw value in using e-mental health applications for bridging the transition from inpatient to outpatient care. Twenty-two professionals and 31 patients completed the questionnaire on reasons not to participate. For the patients, lack of motivation because of too severe depressive symptoms was the most important reason not to participate. For professionals, it was lack of time and high workload.

Conclusions

The current implementation study reveals several important barriers to overcome in order to successfully implement e-mental health in inpatient psychiatric care.

Two sides of the same coin? Patient and therapist experiences with a transdiagnostic blended intervention focusing on emotion regulation

INTRODUCTION

The combination of internet-based intervention and psychotherapy, commonly termed blended therapy (BT), has gained popularity in recent years. While advantages and disadvantages of BT have been identified from the patient and therapist perspective, the two perspectives have rarely been examined within the same treatment. Moreover, almost all available research on patient and therapist experiences with BT is disorder-specific. This study aimed to investigate patient and therapist experiences within the same transdiagnostic BT.

METHODS

A qualitative analysis of semi-structured interviews with eight patients and eight therapists taking part in a transdiagnostic blended intervention focusing on the topic of emotion regulation was conducted. A qualitative content analysis approach was used. Category frequencies were calculated and similarities and differences between the patient and therapist experience were explored.

RESULTS

Ten main themes and 59 subthemes were identified in the category system for patient interviews and ten main themes and 50 subthemes were identified in the category system for therapist interviews. Similarities and differences between the two perspectives were reported with regard to 1) expectations toward the intervention, 2) the internet-based intervention, 3) symptomatology and emotion regulation, 4) the therapeutic relationship and 5) the blended format.

CONCLUSION

This study provides first insights on the experiences with transdiagnostic BT focusing on emotion regulation. Based on the results, different recommendations for the improvement of transdiagnostic BT are made. Future research on patient and therapist experiences with transdiagnostic BT is necessary, in order to further improve the experience of those involved.

Barriers to and Facilitators of Engaging With and Adhering to Guided Internet-Based Interventions for Depression Prevention and Reduction of Pain-Related Disability in Green Professions: Mixed Methods Study

BACKGROUND

Internet-based interventions (IBIs) are effective for the prevention and treatment of mental disorders and are valuable additions for improving routine care. However, the uptake of and adherence to IBIs are often limited. To increase the actual use of IBIs, it is important to identify factors for engaging with and adhering to IBIs.

OBJECTIVE

We qualitatively evaluated barriers and facilitators regarding a portfolio of guided IBIs in green professions (farmers, gardeners, and foresters).

METHODS

Interview participants were selected from 2 randomized controlled trials for either the prevention of depression (Prevention of Depression in Agriculturists [PROD-A]) or the reduction of pain interference (Preventive Acceptance and Commitment Therapy for Chronic Pain in Agriculturists [PACT-A]) in green professions. The intervention group in PROD-A (N=180) participated in an IBI program, receiving access to 1 of 6 symptom-tailored IBIs. The intervention group in PACT-A (N=44) received access to an IBI for chronic pain. Overall, 41 semistructured qualitative interviews were conducted and transcribed verbatim. Barriers and facilitators were identified via inductive qualitative content analysis, with 2 independent coders reaching almost perfect intercoder reliability (Cohen κ=0.92). A quantitative follow-up survey (30/41, 73%) was conducted to validate the results. Subgroup analyses were performed based on intervention characteristics.

RESULTS

We identified 42 barriers and 26 facilitators, which we assigned to 4 superordinate categories related to the intervention (20 barriers; 17 facilitators), work (4 barriers; 1 facilitator), individual (13 barriers; 8 facilitators), and technical (5 barriers; 0 facilitators) aspects. Key barriers (identified by at least 50% of the interviewees) were time-consuming work life (29/40, 73%) and time-consuming private life (23/40, 58%). Similarly, the most frequently identified facilitators included presence of motivation, curiosity, interest and perseverance (30/40, 75%), flexible time management at work (25/40, 63%), and support from family and friends (20/40, 50%). Although agreement with barriers in the quantitative follow-up survey was rather low (mean 24%, SD 11%), agreement with facilitators was substantially higher (mean 80%, SD 13%). Differences in agreement rates were found particularly between intervention completers and noncompleters. Completers agreed significantly more often that perceived IBI success; being motivated, curious, interested, and perseverant; and having a persisting level of psychological strain have been facilitating. Noncompleters agreed more often with experiencing the e-coach contact as insufficient and technical problems as hindering for intervention completion.

CONCLUSIONS

Based on these results, strategies such as customization of modules for more flexible and adaptive use; video chat options with the e-coach; options to facilitate social support by family, friends, or other participants; or using prompts to facilitate training completion can be derived. These approaches could be evaluated in further quantitative research designs in terms of their potential to enhance intervention use in this occupational group.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00014000, https://tinyurl.com/3bukfr48; German Clinical Trials Register DRKS0001461, https://tinyurl.com/ebsn4sns.

Implementation of a psychological online intervention for low to moderate depression in primary care: study protocol

BACKGROUND

Depression affects millions of people all over the world and implies a great socioeconomic burden. Despite there are different effective evidence-based interventions for treating depression, only a small proportion of these patients receives an appropriate treatment. In this regard, information and communication technologies (ICTs) can be used with therapeutic aims and this can contribute to make interventions more accessible. One example is "Smiling is fun", an internet-based treatment which has proved to be effective and cost-effective for treating depression in Spanish Primary Care (PC). However, the "know-do gap" between research and clinical settings implies that the actual implementation of such interventions could last up to 20 years. To overcome this obstacle, the implementation research establishes the methodology to implement the advances developed in the laboratories to the health care services maintaining the validity of the intervention and offering specific strategies for the implementation process.

OBJECTIVE

This is the protocol of an implementation study for the Internet-based program "Smiling is fun", which will be conducted on patients with mild-to-moderate depression of Spanish PC settings. In the implementation study, the feasibility, efficacy, cost-efficacy, acceptability, adoption, appropriateness, fidelity, penetration, normalization, and sustainability will be assessed.

METHODS

The current investigation is a Hybrid Effectiveness-Implementation Type II design. A Stepped Wedge randomized controlled trial design will be used, with a cohort of 420 adults diagnosed with depression (mild-to-moderate) who will undergo a first control phase (no treatment) followed by the intervention, which will last 16 weeks, and finishing with an optional use of the intervention. All patients will be assessed at baseline, during the treatment, and at post-treatment. The study will be conducted in three Spanish regions: Andalusia, Aragon, and the Balearic Islands. Two primary care centers of each region will participate, one located in the urban setting and the other in the rural setting. The primary outcome will be implementation success of the intervention assessing the reach, clinical effect, acceptability, appropriateness, adoption, feasibility, fidelity, penetration, implementation costs and sustainability services.

DISCUSSION

"Smiling is Fun", which has already been established as effective and cost-effective, will be adapted according to users' experiences and opinions, and the efficacy and cost-efficacy of the program will again be assessed. The study will point out barriers and facilitators to consider in the implementation process of internet-based psychological interventions in health services. The ultimate goal is to break the research-to-practice split, which would undoubtedly contribute to reduce the high burden of depression in our society.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT05294614.

Increasing the effectiveness of psychotherapy in routine care through blended therapy with transdiagnostic online modules (PsyTOM): study protocol for a randomized controlled trial

BACKGROUND

In blended therapy, face-to-face psychotherapy and Internet-based interventions are combined. Blended therapy may be advantageous for patients and psychotherapists. However, most blended interventions focus on cognitive behavioral therapy or single disorders, making them less suitable for routine care settings.

METHODS

In a randomized controlled trial, we will compare blended therapy and face-to-face therapy in routine care. We intend to randomize 1152 patients nested in 231 psychotherapists in a 1:1 ratio. Patients in the blended therapy group will receive access to a therapeutic online intervention (TONI). TONI contains 12 transdiagnostic online modules suited for psychodynamic, cognitive behavioral, and systemic therapy. Psychotherapists decide which modules to assign and how to integrate TONI components into the psychotherapeutic process to tailor treatment to their patients' specific needs. We will assess patients at baseline, 6 weeks, 12 weeks, and 6 months. Patients enrolled early in the trial will also complete assessments at 12 months. The primary outcomes are depression and anxiety at 6-month post-randomization, as measured by PHQ-8 and GAD-7. The secondary outcomes include satisfaction with life, level of functioning, personality traits and functioning, eating pathology, sexual problems, alcohol/drug use, satisfaction with treatment, negative effects, and mental health care utilization. In addition, we will collect several potential moderators and mediators, including therapeutic alliance, agency, and self-efficacy. Psychotherapists will also report on changes in symptom severity and therapeutic alliance. Qualitative interviews with psychotherapists and patients will shed light on the barriers and benefits of the blended intervention. Furthermore, we will assess significant others of enrolled patients in a sub-study.

DISCUSSION

The integration of online modules which use a common therapeutic language and address therapeutic principles shared across therapeutic approaches into regular psychotherapy has the potential to improve the effectiveness of psychotherapy and transfer it into everyday life as well help save therapists' resources and close treatment gaps. A modular and transdiagnostic setup of the blended intervention also enables psychotherapists to tailor their treatment optimally to the needs of their patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00028536. Registered on 07.06.2022.

Willingness to Use Internet-Based Versus Bibliotherapy Interventions in a Representative US Sample: Cross-sectional Survey Study

Background

Self-help interventions have the potential to increase access to evidence-based mental health care. Self-help can be delivered via different formats, including print media or digital mental health interventions (DMHIs). However, we do not know which delivery format is more likely to result in higher engagement.

Objective

The aims of this study were to identify if there is a preference for engaging in print media versus DMHIs and whether there are individual differences in relative preferences.

Methods

Participants were 423 adults between the ages of 18 and 82 years (201/423, 47.5% female) recruited on Prolific as a nationally representative sample of the US population, including non-Hispanic White (293/423, 69.2%), non-Hispanic Black (52/423, 12%), Asian (31/423, 7%), Hispanic (25/423, 6%), and other individuals (22/423, 5%). We provided individuals with psychoeducation in different self-help formats and measured their willingness to use print media versus DMHIs. We also assessed participants’ demographics, personality, and perception of each format’s availability and helpfulness and used these to predict individual differences in the relative preferences.

Results

Participants reported being more willing to engage with print media than with DMHIs (B=0.41, SE 0.08; t₄₂₂=4.91; P<.001; d=0.24, 95% CI 0.05-0.43). This preference appeared to be influenced by education level (B=0.22, SE 0.09; t₄₁₃=2.41; P=.02; d=0.13, 95% CI –0.06 to 0.32), perceived helpfulness (B=0.78, SE 0.06; t₄₁₁=13.66; P<.001; d=0.46, 95% CI 0.27-0.66), and perceived availability (B=0.20, SE 0.58; t₄₁₁=3.25; P=.001; d=0.12, 95% CI 0.07-0.30) of the self-help format.

Conclusions

This study suggests an overall preference for print media over DMHIs. Future work should investigate whether receiving mental health treatment via participants’ preferred delivery format can lead to higher engagement.

Australian Psychologists Experiences with Digital Mental Health: a Qualitative Investigation

Digital mental health is changing the landscape of service delivery by addressing challenges associated with traditional therapy. However, practitioners' use of these resources remains underexamined. This study explored psychologists' attitudes and experiences with digital mental health intervention. Taking a qualitative exploratory approach via thematic analysis, the study sought to answer the following research questions: (i) How do psychologists perceive digital mental health? and (ii) What is their experience using digital mental health as part of routine practice? Ten practising psychologists participated in online semi-structured interviews (approximately 50 min), with interviews then transcribed verbatim. Interview data were analysed according to the six-phase approach to thematic analysis proposed by Braun and Clarke. Three themes were identified: (1) attitudes towards digital mental health; (2) use within routine practice; and (3) perspectives on an effective model for implementation. Practitioners play a major role in the design and delivery of digital mental health services. Barriers and facilitators at the practitioner-level (e.g. knowledge and competence with tools, perceptions on the utility of digital interventions) and the service-level (e.g. government support for digital health) should be considered in the future design of digital mental health resources and service delivery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41347-022-00271-5.

Trainee Therapists' Perceptions of a Blended Intervention to Promote Resilience after a Natural Disaster: A Qualitative Case Study

BACKGROUND

Natural disasters happen in an increased frequency, and telemental health interventions could offer easily accessible help to reduce mental health symptoms experienced by survivors. However, there are very few programs offered to natural disaster survivors, and no research exists on therapists' experiences with providing blended interventions for natural disaster survivors.

AIMS

Our qualitative case study aims to describe psychologists' experiences with an online, therapist-assisted blended intervention for survivors of the Fort McMurray wildfires in Alberta, Canada.

METHOD

The RESILIENT intervention was developed in the frames of a randomized controlled trial to promote resilience after the Fort McMurray wildfires by providing survivors free access to a 12-module, therapist-assisted intervention, aiming to improve post-traumatic stress, insomnia, and depression symptoms. A focus group design was used to collect data from the therapists, and emerging common themes were identified by thematic analysis.

RESULTS

Therapists felt they could build strong alliances and communicate emotions and empathy effectively, although the lack of nonverbal cues posed some challenges. The intervention, according to participating therapists, was less suitable for participants in high-stress situations and in case of discrepancy between client expectations and the intervention content. Moreover, the therapists perceived specific interventions as easy-to-use or as more challenging based on their complexity and on the therapist support needed for executing them. Client engagement in the program emerged as an underlying theme that had fundamental impact on alliance, communication, and ultimately, treatment efficiency. Therapist training and supervision was perceived as crucial for the success of the program delivery.

CONCLUSIONS

Our findings provided several implications for the optimalization of blended interventions for natural disaster survivors from our therapists' perspective.

Practitioners' experience of the working alliance in a blended cognitive-behavioural therapy intervention for depression: qualitative study of barriers and facilitators

BACKGROUND

Digital technologies have been widely acknowledged as a potentially useful resource for increasing mental healthcare access. The working alliance is a key influence on outcomes in conventional psychotherapy, but little is known about therapists' experiences of forming an effective working alliance in blended interventions that involve in-person psychotherapy and a digital programme.

AIMS

To investigate psychological well-being practitioners' (PWPs') experiences of the working alliance in a trial of blended cognitive-behavioural therapy (b-CBT) for depression. Trial registration ISRCTN12388725.

METHOD

Semi-structured qualitative interviews were conducted with 13 PWPs who delivered b-CBT in a two-arm, non-inferiority randomised controlled trial investigating the effectiveness of b-CBT compared with face-to-face CBT. Thematic analysis was used to analyse the data.

RESULTS

Participants reported four facilitating factors when building and maintaining a working alliance in b-CBT: having more time to deliver treatment, access to a wider toolkit, capacity to tailor components of b-CBT and receiving appropriate training and support. Participants also identified four barriers to building and maintaining a working alliance: time and resource constraints, usability challenges, limited flexibility to tailor the digital programme to patients' needs and lack of confidence in delivering b-CBT.

CONCLUSIONS

Our study is the first specifically to investigate practitioners' perceived facilitators and barriers to forming a working alliance in b-CBT for depression. Findings suggest that PWPs' experiences of the working alliance can be improved by: accounting for the time required to deliver b-CBT in service workflows to reduce time pressures; increasing opportunities to tailor the digital programme through offering transdiagnostic tools and adaptable features; and providing appropriate b-CBT training and technical support.

Das Beste aus zwei Welten: Eine systematische Übersicht zu Faktoren der Implementierung einer “Blended Therapy” (Gemischte Therapie) in der Psychotherapeutischen Routineversorgung

<b><i>Ziel:</i></b> Diese Arbeit gibt einen Überblick über bisherige wissenschaftliche Empfehlungen zur Implementierung der blended therapy, d.h. der Kombination von Therapien in Präsenz und via digitaler Medien. Die Empfehlungen um­fassen die Themen: (1) wahrgenommene Barrieren von Psychotherapeut*innen, (2) Format der blended therapy und (3) Indikationen für Patient*innen. In diesem Rahmen werden Faktoren aufgezeigt, die Akteur*innen im Gesundheitssystem als Orientierung dienen können, welche Determinanten bei der Implementierung in die Routineversorgung zu berücksichtigen sind. <b><i>Methodik:</i></b> Die systematische Suche erfolgte in den Datenbanken PsycArticles, PsycInfo, PSYNDEX und PubMed. <b><i>Ergebnisse:</i></b> Die Publikationen umfassen vier quantitative, neun qualitative sowie drei Mixed-Methods-Studien. Die bisherigen Arbeiten kommen zu dem Ergebnis, dass Psychotherapeut*innen frühzeitig in den Implementierungsprozess einbezogen und langfristige supportive Maßnahmen für die Umstrukturierung der bisherigen Arbeitsroutine geschaffen werden sollten. Das Format der blended therapy sollte nicht standardisiert angewandt, sondern vielmehr individuell an die Patient*innen angepasst werden. Hinsichtlich möglicher Indikationen werden verschiedene Einflussfaktoren der Patient*innen diskutiert, die bisher jedoch nur unzureichend untersucht wurden. <b><i>Diskussion:</i></b> Bisherige Studien weisen größtenteils homogene Charakteristika und Ergebnisse auf. Forschungslücken bestehen hinsichtlich der Frage, inwieweit sich die Ergebnisse auf andere Therapieschulen, Berufsgruppen und Störungsbilder übertragen lassen. <b><i>Schlussfolgerung:</i></b> Das Review veranschaulicht, dass es wichtiger Vorarbeit hinsichtlich der Anwendungsunterstützung für Psychotherapeut*innen sowie weiterer Forschungsaktivität bedarf, um die Implementierung von blended therapy im Sinne einer möglichen Verbesserung der psychotherapeutischen Versorgung voranzutreiben.

A systematic quality rating of available mobile health apps for borderline personality disorder

BACKGROUND

Mobile health apps (MHAs) may offer a mean to overcome treatment barriers in Borderline Personality Disorder (BPD) mental health care. However, MHAs for BPD on the market lack transparency and quality assessment.

METHODS

European app stores were systematically searched, and two independent trained reviewers extracted relevant MHAs. Employed methods and privacy and security details documentation of included MHAs were extracted. MHAs were then assessed and rated using the German version of the standardized Mobile Application Rating Scale (MARS-G). Mean values and standard deviations of all subscales (engagement, functionality, aesthetics, information, and therapeutic gain) and correlations with user ratings were calculated.

RESULTS

Of 2977 identified MHAs, 16 were included, showing average quality across the four main subscales (M = 3.25, SD = 0.68). Shortcomings were observed with regard to engagement (M = 2.87, SD = 0.99), potential therapeutic gain (M = 2.67, SD = 0.83), existing evidence base (25.0% of included MHAs were tested empirically), and documented privacy and security details. No significant correlations were found between user ratings and the overall total score of the MARS-G or MARS-G main subscales.

CONCLUSIONS

Available MHAs for BPD vary in quality and evidence on their efficacy, effectiveness, and possible adverse events is scarce. More substantial efforts to ensure the quality of MHAs available for patients and a focus on transparency, particularly regarding privacy and security documentation, are necessary.

Organisational implementation climate in implementing internet-based cognitive behaviour therapy for depression

Background

Internet-based Cognitive Behaviour Therapy (iCBT) for depression have been implemented in routine care across Europe in varying ways, at various scales and with varying success. This study aimed to advance our understanding of organisational implementation climate from the perspectives of implementers and mental health service deliverers.

Methods

Qualitative and quantitative methods were combined to study the concept of organisational implementation climate in mental health care settings. Based on concept mapping, a qualitative workshop with implementers was used to conceptualise organisational implementation climate for optimizing iCBT use in routine practice. Service deliverers involved in the provision of iCBT were invited to participate in an explorative cross-sectional survey assessing levels of satisfaction and usability of iCBT, and organisational implementation climate in implementing iCBT. The two methods were applied independently to study viewpoints of implementers as well as service deliverers. Corresponding to the explorative nature of the study, inductive reasoning was applied to identify patterns and develop a reasonable explanation of the observations made. Correlative associations between satisfaction, usability and implementation climate were explored.

Results

Sixteen implementers representing fourteen service delivery organisations across Europe participated in the workshop. The top-three characteristics of a supportive organisational implementation climate included: (1) clear roles and skills of implementers, (2) feasible implementation targets, and (3) a dedicated implementation team. The top-three tools for creating a supportive implementation climate included: (1) feedback on job performance, (2) progress monitoring in achieving implementation targets, and (3) guidelines for assessing the impact of iCBT. The survey (n=111) indicated that service providers generally regarded their organisational implementation climate as supportive in implementing iCBT services. Organisational implementation climate was weakly associated with perceived usability and moderately with satisfaction with iCBT services.

Conclusions

Organisational implementation climate is a relevant factor to implementers and service deliverers in implementing iCBT in routine care. It is not only an inherent characteristic of the context in which implementation takes place, it can also be shaped to improve implementation of iCBT services. Future research should further theorise organisational implementation climate and empirically validate the measurement instruments such as used in this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08041-y.

Usability, Feasibility, and Effect of a Biocueing Intervention in Addition to a Moderated Digital Social Therapy-Platform in Young People With Emerging Mental Health Problems: A Mixed-Method Approach

Introduction

To optimize treatment, it is of utmost importance to take into account the myriad of biological, social, and psychological changes that young people go through during adolescence which make them more vulnerable for developing mental health problems. Biocueing, a non-invasive method to transform physiological parameters into an observable signal, could strengthen stress- and emotion regulation by cueing physiologically unusual values in daily life. The aim of this study is to investigate the usability, feasibility, and exploratory effect of biocueing in addition to ENgage YOung people earlY (ENYOY), a moderated digital social therapy-platform, in young people with emerging mental health complaints.

Methods

A user-centered mixed-method design was used. A focus group was conducted to optimize the ENYOY-platform and biocueing intervention. Biocueing was operationalized by a smartwatch and the Sense-IT app. A within-subjects design was used; 10 days for all participants 'biofeedback off' (control), followed by 10 days 'biofeedback on' (experimental). Emotional awareness and perceived stress were measured using ecological momentary assessment. Eight individuals participated. User-friendliness, usability, and acceptance were assessed using a qualitative design.

Results

Findings from the focus group resulted in several adaptations of the biocueing intervention to the ENYOY-platform and vice versa. The average measurement compliance rate was 78.8%. Level-one findings showed different individual effects on perceived stress and emotional awareness. Level-two analyses showed no overall effects on perceived stress (B = -0.020, p = 0.562) and overall positive effects on emotional awareness (B = 0.030, p = 0.048) with small effect sizes (Improvement Rate Difference = 0.05-0.35). The intervention was found to be acceptable and showed moderate usability. Participants indicated they experienced improvements in reflection on feelings and changes in behavior, such as pausing and evaluating the situation.

Conclusion

These preliminary results show that biocueing could be a promising addition to digital treatment platforms and help young people become more emotionally aware. Improvements should be made regarding the usability and acceptability of the smartwatch, as well as more extensive integration of the biocueing intervention with a digital treatment platform. It would be relevant to gain a better understanding of which individuals would benefit most from an additional biocueing intervention.

Making remote measurement technology work in multiple sclerosis, epilepsy and depression: survey of healthcare professionals

Background

Epilepsy, multiple sclerosis (MS) and depression are long term, central nervous system disorders which have a significant impact on everyday life. Evaluating symptoms of these conditions is problematic and typically involves repeated visits to a clinic. Remote measurement technology (RMT), consisting of smartphone apps and wearables, may offer a way to improve upon existing methods of managing these conditions. The present study aimed to establish the practical requirements that would enable clinical integration of data from patients’ RMT, according to healthcare professionals.

Methods

This paper reports findings from an online survey of 1006 healthcare professionals currently working in the care of people with epilepsy, MS or depression. The survey included questions on types of data considered useful, how often data should be collected, the value of RMT data, preferred methods of accessing the data, benefits and challenges to RMT implementation, impact of RMT data on clinical practice, and requirement for technical support. The survey was presented on the JISC online surveys platform.

Results

Among this sample of 1006 healthcare professionals, respondents were positive about the benefits of RMT, with 73.2% indicating their service would be likely or highly likely to benefit from the implementation of RMT in patient care plans. The data from patients’ RMT devices should be made available to all nursing and medical team members and could be reviewed between consultations where flagged by the system. However, results suggest it is also likely that RMT data would be reviewed in preparation for and during a consultation with a patient. Time to review information is likely to be one of the greatest barriers to successful implementation of RMT in clinical practice.

Conclusions

While further work would be required to quantify the benefits of RMT in clinical practice, the findings from this survey suggest that a wide array of clinical team members treating epilepsy, MS and depression would find benefit from RMT data in the care of their patients. Findings presented could inform the implementation of RMT and other digital interventions in the clinical management of a range of neurological and mental health conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01856-z.

A Blended Cognitive–Behavioral Intervention for the Treatment of Postpartum Depression: A Case Study

Postpartum depression is a highly prevalent mental health problem with harmful consequences for women, babies, and mother–infant relationships. Cognitive–behavioral therapy (CBT) is among the most effective treatment options for postpartum depression. However, a large number of postpartum women do not seek professional help, suggesting the need for new treatment delivery formats. The present article describes the application of Be a Mom Coping with Depression, a blended CBT treatment for postpartum depression, for a 31-year-old postpartum woman. The intervention was provided over a period of 13 weeks, integrating seven biweekly sessions with a psychologist and six sessions within an online program, and it is described in detail. A summary of the patient’s progress and the results obtained throughout treatment is reported. At the end of the intervention, a significant decrease in depressive and anxiety symptoms was observed, as well as increased perceived maternal self-efficacy, higher psychological flexibility, and higher self-compassion. This case study provides encouraging data for the preliminary evidence of the acceptability, feasibility, and efficacy of the Be a Mom Coping with Depression intervention in the reduction of depressive symptoms during the postpartum period. Advantages of this treatment format and implications for clinical practice and future research are discussed.

Understanding Mental Health Professionals' Perspectives and Practices Regarding the Implementation of Digital Mental Health: Qualitative Study

BACKGROUND

Despite the potential of digital mental health to provide cost-effective mental health care, its adoption in clinical settings is limited, and little is known about the perspectives and practices of mental health professionals regarding its implementation or the factors influencing these perspectives and practices.

OBJECTIVE

This study aims to characterize in depth the perspectives and practices of mental health professionals regarding the implementation of digital mental health and explore the factors affecting such perspectives and practices.

METHODS

A qualitative study using in-depth semistructured interviews with Portuguese mental health professionals (N=13)-psychologists and psychiatrists-was conducted. The transcribed interviews were thematically analyzed.

RESULTS

Mental health professionals deemed important or engaged in the following practices during the implementation of digital mental health: indication evaluation, therapeutic contract negotiation, digital psychological assessment, technology setup and management, and intervention delivery and follow-up. Low-threshold accessibility and professionals' perceived duty to provide support to their clients facilitated the implementation of digital mental health. Conversely, the lack of structured intervention frameworks; the unavailability of usable, validated, and affordable technology; and the absence of structured training programs inhibited digital mental health implementation by mental health professionals.

CONCLUSIONS

The publication of practice frameworks, development of evidence-based technology, and delivery of structured training seem key to expediting implementation and encouraging the sustained adoption of digital mental health by mental health professionals.

Couple and family therapists’ experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants’ initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients’ privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients’ raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a “participant observer” to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

Acceptance of E-Mental Health Services for Different Application Purposes Among Psychotherapists in Clinical Training in Germany and Switzerland: Secondary Analysis of a Cross-Sectional Survey

Background

Despite solid evidence supporting the efficacy of electronic mental health (EMH) services, their acceptance among psychotherapists is limited and uptake rates remain low. However, the acceptance of different EMH services has yet barely been examined in future generations of psychotherapists in a differentiated manner. The aims of this study were (1) to elaborate the intention to use various EMH services for different application purposes and (2) to determine predictors of EMH service acceptance among psychotherapists in clinical training (PiT).

Materials and Methods

Our paper is based on a secondary data analysis of a cross-sectional survey. Respondents were recruited via recognized educational institutions for psychotherapy within Germany and the German-speaking part of Switzerland between June and July of 2020. The survey contained items on the intention to use different EMH services (i.e., guided and unguided programs, virtual reality, psychotherapy by telephone and videoconference) for various application purposes (i.e., prevention, treatment addition, treatment substitute, aftercare). Potential predictors of EMH service acceptance (e.g., barriers and advantages) were examined based on an extension of the Unified Theory of Acceptance and Use of Technology (UTAUT).

Results

Most of the n = 216 respondents were female (88.4%) and located in Germany (72.2%). General acceptance of EMH was moderate (M = 3.4, SD = 1.12, range 1-5), while acceptance of psychotherapy via videoconference was highest (M = 3.7, SD = 1.15) and acceptance of unguided programs was lowest (M = 2.55, SD = 1.14). There was an interaction effect of EMH service and application purpose (η2 = 0.21). Barriers and advantages both had a uniform influence on EMH service acceptance (Pr > 0.999), while impersonality, legal concerns, concerns about therapeutic alliance, simplified information provision, simplified contact maintenance, time flexibility, and geographic flexibility were significant predictors (all p < 0.05). Results showed that the extended UTAUT model was the best fitting model to predict EMH service acceptance (Pr > 0.999).

Conclusions

The intention to use different EMH services varied between application purposes among PiT. To increase acceptance of EMH services and reduce misconceptions, we identified predictors that should be addressed in future acceptance-facilitating interventions when educating PiT.

Online therapy: an added value for inpatient routine care? Perspectives from mental health care professionals

Internet-delivered interventions can be effective in treating mental disorders. However, their rate of use in German psychiatric inpatient routine care is low. The current study aimed to investigate the attitude of mental health care professionals working in inpatient care regarding internet-delivered interventions, including presumed benefits, barriers and facilitators. In total, 176 health professionals from ten inpatient psychiatric hospitals throughout Germany were surveyed on site. The professionals' attitude towards internet-delivered interventions in inpatient care was assessed by an adapted version of the 'Attitude toward Telemedicine in Psychiatry and Psychotherapy' (ATTiP) questionnaire. To identify benefits, barriers and facilitators, we developed open-response questions that were based on the 'Unified Theory of Acceptance and Use of Technology' (UTAUT) and analyzed by a qualitative content analysis. Professionals reported little experience or knowledge about internet-delivered interventions. Their attitude towards internet-delivered interventions in psychiatric inpatient care was rather indifferent. The most frequently mentioned potential benefits were an optimised treatment structure and patient empowerment; the most frequently anticipated barriers were too severe symptoms of patients, the feared neglect of face-to-face contacts and insufficient technical equipment; and the most frequently mentioned facilitators were high usability of the internet-based intervention, a sufficient functional level of the patient and further education of staff. For successful implementation in the inpatient sector, internet-delivered interventions must be adapted to the special needs of severely mentally ill patients and to the hospital management systems and workflow. In addition, technical preconditions (internet access, devices) must be met. Last, further education of mental health care professionals is needed.

Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster

BACKGROUND

Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND.

OBJECTIVE

This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT).

METHODS

In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up.

RESULTS

Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups.

CONCLUSIONS

In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364683&isReview=true.

A blended rational emotive occupational health coaching for job-stress among teachers of children with special education needs

BACKGROUND/OBJECTIVES

Heightened stress tends to undermine both teachers' efficacy and students' outcomes. Managing job stress in teachers of children with special education needs is continually recommended due to the increased demands for the teachers to adapt curriculum content, learning materials and learning environments for learning. This study investigated the efficacy of blended Rational Emotive Occupational Health Coaching in reducing occupational stress among teachers of children with special needs in Abia State, Nigeria.

METHOD

The current study adopted a group-randomized waitlist control trial design with pretest, post-test and follow-up assessments. Participants (N = 83) included teachers of children with special education needs in inclusive and specialized schools. The bREOHC group was exposed to intersession face-to-face and online REOC program weekly for twelve (12) weeks. Data were collected using Single Item Stress Questionnaire (SISQ), Teachers' Stress Inventory and Participants' Satisfaction questionnaire (PSQ). Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures ANOVA and bar charts.

RESULTS

Results revealed that the mean perceived stress, stress symptoms and the total teachers' stress score of the bREOHC group at post-test and follow up assessments reduced significantly, compared to the waitlisted group. Participants also reported high level of satisfaction with the therapy and procedures.

CONCLUSION

From the findings of this study, we conclude that blended REOHC is efficacious in occupational stress management among teachers of children with special education needs.

Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up

BACKGROUND

Anxiety disorders are highly prevalent and cause substantial economic burden. Blended cognitive-behavioural therapy (bCBT), which integrates Internet-based CBT and face-to-face CBT (ftfCBT), is an attractive and potentially cost-saving treatment alternative to conventional CBT for patients with anxiety disorders in specialised mental health care. However, little is known about the effectiveness of bCBT in routine care. We examined the acceptability, effectiveness and cost-effectiveness of bCBT versus ftfCBT in outpatient specialised care to patients with panic disorder, social anxiety disorder and generalised anxiety disorder.

METHODS AND FINDINGS

Patients with anxiety disorders were randomised to bCBT (n = 52) or ftfCBT (n = 62). Acceptability of bCBT and ftfCBT were evaluated by assessing treatment preference, adherence, satisfaction and therapeutic alliance. Costs and effects were assessed at post-treatment and one-year follow-up. Primary outcome measure was the Beck Anxiety Inventory (BAI). Secondary outcomes were depressive symptoms, general psychopathology, work and social adjustment, quality of life and mastery. Incremental cost-effectiveness ratios (ICERs) were computed from societal and healthcare perspectives by calculating the incremental costs per incremental quality-adjusted life year (QALY). No significant differences between bCBT and ftfCBT were found on acceptability or effectiveness measures at post-treatment (Cohen's d between-group effect size on BAI = 0.15, 95% CI -0.30 to 0.60) or at one-year follow-up (d = -0.38, 95% CI -0.84 to 0.09). The modelled point estimates of societal costs (bCBT €10945, ftfCBT €10937) were higher and modelled point estimates of direct medical costs (bCBT €3748, ftfCBT €3841) were lower in bCBT. The acceptability curves showed that bCBT was expected to be a cost-effective intervention. Results should be carefully interpreted due to the small sample size.

CONCLUSIONS

bCBT appears an acceptable, clinically effective and potentially cost-saving alternative option for treating patients with anxiety disorders. Trials with larger samples are needed to further investigate cost-effectiveness.

TRIAL REGISTRATION

Netherlands Trial Register: NTR4912.