Therapist-assisted Internet-delivered cognitive behavior therapy for depression and anxiety: translating evidence into clinical practice

A scoping review of therapist behaviors in guided digital mental health interventions

Guided digital mental health interventions are more effective than unguided interventions. While research often emphasizes the frequency and intensity of guidance, less attention has been paid to the behaviors enacted by the therapists supporting clients using these interventions. A scoping review of the literature was conducted to systematically examine the evidence on therapist behaviors (i.e., the actions and feedback provided by supporters to patients). Applying broad eligibility criteria, a systematic search was conducted in PubMed, PsycInfo, the Cochrane Library, and Embase from their inception to January 1st 2024. Sixteen studies met inclusion criteria and were included in the review. Following data extraction, a descriptive analysis and synthesis of the results was performed. Most studies (n = 12; 75 %) focused on therapist behaviors in the context of internet-delivered Cognitive Behavioral Therapy for anxiety and depression. While earlier studies primarily focused on identifying therapist behaviors, later studies shifted towards examining the associations between therapist behaviors and different outcomes, as well as deriving research and clinical applications for improving guided internet-delivered treatments. Identified gaps and recommendations for clinical practice, research, training, and treatment development are discussed.

Internet-Based Cognitive-Behavioral Therapy for Individuals Experiencing Panic Attacks: A Scoping Literature Review

Panic attacks (PAs) are prevalent and highly comorbid with various physical and psychological disorders. Cognitive-behavioral therapy (CBT) is a well-established psychosocial intervention. Internet-delivered CBT (ICBT) presents a promising avenue to overcome barriers and provide evidence-based support to those in need. The current scoping review aimed to systematically map the existing literature and identify knowledge gaps regarding the impact of ICBT on outcome measures for individuals experiencing PAs. The PRISMA guidelines for scoping reviews were used. A total of 3,044 records were retrieved, and 18 studies from 2013 to 2023 were ultimately included in the analysis. ICBT demonstrated effectiveness as a psychosocial intervention for improving panic symptoms and anxiety in individuals with PAs. However, the impact of ICBT on quality of life (QOL) remains inconclusive. All studies included in this review focused on assessing the severity of panic symptoms, with limited emphasis on measuring QOL. This scoping review holds significant implications for research and practice. However, further addressing the research needs identified in this review will enhance our understanding and improve treatment outcomes for PAs. [Journal of Psychosocial Nursing and Mental Health Services, 62(4), 9-15.].

Effectiveness of online cognitive behavioural therapy on quality of life in adults with depression: A systematic review

WHAT IS KNOWN ON THE SUBJECT

Depression is a leading cause of disability worldwide that negatively impacts quality of life. Talk therapy such as cognitive behavioural therapy is an effective treatment for depression. The Internet is an important tool for mental healthcare delivery. Internet-delivered or online talk therapy interventions are associated with lower costs and improved accessibility. Current reviews do not address the effectiveness of Internet-delivered cognitive behavioural therapy (iCBT) on quality of life (QoL).

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Interventions for iCBT have better QoL improvements for individuals with greater depressive symptom severity, females, young adults and individuals with complex comorbid disorders. Support from a healthcare provider for iCBT interventions have better outcomes than self-guided therapy interventions. Tailoring the iCBT intervention to the specialized needs of the population is beneficial.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

There is potential to address treatment gaps for managing the care of individuals with depression. Utilizing iCBT promotes the integration of accessible mental healthcare in clinical settings. Healthcare providers can have a more comprehensive approach to delivering iCBT by considering adaptations relevant to the clinical population being treated.

ABSTRACT

INTRODUCTION: Major depressive disorder (MDD) is a leading cause of disability resulting from social, psychological and biological factors affecting quality of life (QoL). Cognitive behavioural therapy (CBT) is an effective psychotherapy for MDD. Internet-delivered CBT (iCBT) is associated with lower costs and improved accessibility.

AIM

We aimed to examine the effectiveness of iCBT on QoL in adults with depression.

METHOD

PubMed, Embase and PsycINFO were searched between 2010 and 2022. Inclusion criteria were experimental designs, adults ≥18 years old, depression diagnosis or valid self-report measure, iCBT intervention; and QoL outcome. Exclusion criteria were studies without depression analysis and intellectual disabilities or psychosis.

RESULTS

Seventeen articles were included, with a negative correlation between depression severity and QoL. Sex, age and physical comorbidity positively influenced effectiveness. Depressive severity, dysfunctional attitude and negative thinking were predictors and moderators of QoL. Clinician support can impact social interactions and sense of belonging.

DISCUSSION

Internet-delivered cognitive behavioural therapy is effective for improving QoL in adults with MDD. Severe depression, females, younger age and comorbid disorders were associated with greater QoL improvements.

IMPLICATIONS FOR PRACTICE

The findings suggest iCBT could address depression treatment gaps related to improving QoL. Utilizing iCBT potentially improves the care continuum for individuals with complex disorders.

Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders

Assessment of treatment response in psychotherapies can be undermined by lack of longitudinal measurement invariance (LMI) in symptom self-report inventories, by measurement error, and/or by wrong model assumptions. To understand and compare these threats to validity of outcome assessment in psychotherapy research, we studied LMI, sum scores, and Davidian Curve Item Response Theory models in a naturalistic guided internet psychotherapy treatment register of 2,218 generalized anxiety disorder (GAD) patients and 3,922 depressive disorder (DD) patients (aged ≥16 years). Symptoms were repeatedly assessed by Generalized Anxiety Disorder Assessment-7 (GAD-7) or Beck Depression Inventory. The symptom self-reports adhered to LMI under equivalence testing, suggesting sum scores are reasonable proxies for disorder status. However, the standard LMI assumption of normally distributed latent factors did not hold and inflated treatment response estimates by 0.2 to 0.3 standard deviation units compared with sum scores. Further methodological research on non-normally distributed latent constructs holds promise in advancing LMI and mental health assessment.

Remote cognitive-behavioral therapy for generalized anxiety disorder: A preliminary meta-analysis

BACKGROUND

Generalized anxiety disorder (GAD) is a chronic mental health condition that results in significant individual, societal, and economic burden. While cognitive behavioral therapy (CBT) is well established as an efficacious treatment for GAD, individuals have identified several logistical barriers to accessing face-to-face CBT. Remotely delivered treatments address many of these treatment barriers.

METHODS

The aim of the current study was to synthesize the current literature on the efficacy of remote CBT for GAD using a meta-analytic approach. Relevant articles were identified through an electronic database search and 10 studies (with 11 remote conditions and 1071 participants) were included in the meta-analysis.

RESULTS

Within-group findings indicate that remote CBT for GAD results in large effect sizes from pretreatment to posttreatment (g = 1.30; 95% confidence interval [CI]: 1.03-1.58). Both low intensity and high intensity remote CBT interventions were found to result in large effect sizes (g = 1.36; 95% CI: 1.11-1.61 and g = 0.83; 95% CI: 0.20-1.47, respectively), with no significant differences between the treatment formats (Q₁  = 2.28, p = 0.13). Between-group effect sizes were medium in size at posttreatment (g = 0.76; 95% CI: 0.47-1.06).

CONCLUSIONS

These findings have potential implications for the delivery of evidence-based treatment for GAD and the inclusion of remote methods in stepped care treatment approaches.

Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Symptoms of Postpartum Anxiety and Depression: Feasibility Randomized Controlled Trial

Background

Postpartum depression (PPD) and postpartum anxiety (PPA) are often comorbid and are associated with significant personal and economic costs. Fewer than half of the mothers experiencing PPD or PPA symptoms receive face-to-face treatment, suggesting a need for alternative delivery formats such as internet-delivered cognitive behavioral therapy (ICBT).

Objective

This pilot study aimed to examine the impact of a therapist-assisted, transdiagnostic ICBT program on symptoms of PPD and PPA, as there is only one previous study on transdiagnostic ICBT with this population, which did not include therapist assistance.

Methods

Clients endorsing the symptoms of PPD or PPA (N=63) were randomized to an 8-week transdiagnostic ICBT course (Wellbeing Course for New Moms) or to treatment as usual (TAU). Clients completed measures of depression, anxiety, stress, postnatal bonding, and relationship satisfaction, as well as measures of treatment satisfaction and therapeutic alliance, before treatment, after treatment, and at the 1-month follow-up. Outcome measures were also completed at the 6-month follow-up for clients who completed the ICBT course.

Results

Both the ICBT and TAU groups experienced statistically significant improvements over time. The ICBT group experienced larger improvements after treatment and at the 1-month follow-up on more measures than the TAU group, with medium between-group Cohen d effects on primary outcome measures for anxiety (Cohen d=0.65, 95% CI 0.13-1.17), PPD (Cohen d=0.52, 95% CI 0.01-1.04), and depression (Cohen d=0.56, 95% CI 0.05-1.08), and on secondary outcome measures of overall distress (Cohen d=0.69, 95% CI 0.17-1.21), anxiety (Cohen d=0.59, 95% CI 0.07-1.11), and stress (Cohen d=0.76, 95% CI 0.23-1.28). Time-by-group interactions for proportional reductions between groups over time were only significant after treatment and at the 1-month follow-up for the primary anxiety measure (P=.006). This study was underpowered for detecting small or medium effects. Overall, clients perceived the treatment as credible, and 95% (21/22) of the clients were satisfied with the treatment content and therapist support.

Conclusions

Findings from this pilot study provide preliminary support for transdiagnostic ICBT in treating PPD and PPA symptoms to improve access to psychological treatments.

Trial Registration

ClinicalTrials.gov NCT04012580; https://clinicaltrials.gov/ct2/show/NCT04012580

Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study

Background

Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care.

Objective

In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care.

Methods

We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale.

Results

Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7–measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ≥10, approximately 421 (47.1%) achieved reliable recovery.

Conclusions

This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital–iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients.

Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

Background

Strategies to improve access to evidence-based psychological treatments (EBPTs) include but are not limited to implementation strategies. No currently available framework accounts for the full scope of strategies available to allow stakeholders to improve access to EBPTs. Anxiety disorders are common and impactful mental conditions for which EBPTs, especially cognitive-behavioral therapies (CBT), are well-established yet often hard to access.

Objective

Describe and classify the various strategies reported to improve access to CBT for anxiety disorders.

Methods

Scoping review with a keyword search of several databases + additional grey literature documents reporting on strategies to improve access to CBT for anxiety disorders. A thematic and inductive analysis of data based on grounded theory principles was conducted using NVivo.

Results

We propose to classify strategies to improve access to CBT for anxiety disorders as either "Contributing to the evidence base," "Identifying CBT delivery modalities to adopt in practice," "Building capacity for CBT delivery," "Attuning the process of access to local needs," "Engaging potential service users," or "Improving programs and policies." Each of these strategies is defined, and critical information for their operationalization is provided, including the actors that could be involved in their implementation.

Implications

This scoping review highlights gaps in implementation research regarding improving access to EBPTs that should be accounted for in future studies.

Web-Based Interventions to Help Australian Adults Address Depression, Anxiety, Suicidal Ideation, and General Mental Well-being: Scoping Review

BACKGROUND

A large number of Australians experience mental health challenges at some point in their lives. However, in many parts of Australia, the wait times to see general practitioners and mental health professionals can be lengthy. With increasing internet use across Australia, web-based interventions may help increase access to timely mental health care. As a result, this is an area of increasing research interest, and the number of publicly available web-based interventions is growing. However, it can be confusing for clinicians and consumers to know the resources that are evidence-based and best meet their needs.

OBJECTIVE

This study aims to scope out the range of web-based mental health interventions that address depression, anxiety, suicidal ideation, or general mental well-being and are freely available to Australian adults, along with their impact, acceptability, therapeutic approach, and key features.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews (PRISMA-ScR [PRISMA extension for Scoping Reviews]) guided the review process. Keywords for the search were depression, anxiety, suicide, and well-being. The search was conducted using Google as well as the key intervention databases Beacon, Head to Health, and e-Mental Health in Practice. Interventions were deemed eligible if they targeted depression, anxiety, suicidal ideation, or general mental well-being (eg, resilience) in adults; and were web-based, written in English, interactive, free, and publicly available. They also had to be guided by an evidence-based therapeutic approach.

RESULTS

Overall, 52 eligible programs were identified, of which 9 (17%) addressed depression, 15 (29%) addressed anxiety, 13 (25%) addressed general mental well-being, and 13 (25%) addressed multiple issues. Only 4% (2/52) addressed distress in the form of suicidal ideation. The most common therapeutic approach was cognitive behavioral therapy. Half of the programs guided users through exercises in a set sequence, and most programs enabled users to log in and complete the activities on their own without professional support. Just over half of the programs had been evaluated for their effectiveness in reducing symptoms, and 11% (6/52) were being evaluated at the time of writing. Program evaluation scores ranged from 44% to 100%, with a total average score of 85%.

CONCLUSIONS

There are numerous web-based programs for depression, anxiety, suicidal ideation, and general well-being, which are freely and publicly available in Australia. However, identified gaps include a lack of available web-based interventions for culturally and linguistically diverse populations and programs that use newer therapeutic approaches such as acceptance and commitment therapy and dialectical behavior therapy. Despite most programs included in this review being of good quality, clinicians and consumers should pay careful attention when selecting which program to recommend and use, as variations in the levels of acceptability and impact of publicly available programs do exist.

Predictors of Treatment Response to an Internet-Delivered Intervention Targeting Residual Cognitive Symptoms After Major Depressive Disorder

OBJECTIVE

Residual cognitive symptoms after depression are common and associated with reduced daily life functioning and an increased risk of depression relapse. There is a lack of knowledge on treatments targeting residual cognitive symptoms after major depressive disorder (MDD), including the factors associated with treatment response. The aim of the current study is to explore factors of treatment response to a guided internet-delivered intervention for former depressed adults experiencing residual cognitive symptoms.

METHOD

Forty-three former depressed adults with residual cognitive symptoms were included. Linear mixed model analyses were used to investigate the impact of pre-treatment demographic-, illness, and symptom variables, and therapy process variables, such as credibility, expectancy, and user behavior, on reduction in residual cognitive symptoms from pre-treatment to 6-month follow-up.

RESULTS

Having had MDD for a year or less predicted more reductions in residual cognitive symptoms from pre- to 6-month follow-up. Higher levels of perceived treatment credibility and expectancy evaluated in the early course of treatment did also predict a positive treatment response. No demographic-, symptom-variables, previous number of episodes with MDD, and user behavior were associated with change in residual cognitive symptoms.

CONCLUSION

This study suggests that individuals with shorter duration of previous depressions might have larger reductions in residual cognitive symptoms at 6-month follow-up compared to those with a longer duration of depression. Treatment credibility and expectancy also predicted treatment response and effort should also be made to ensure interventions credibility. Results should be interpreted with caution due to the study having a low sample size. Further investigation of predictors should be conducted in a full scale randomized controlled trial.

Sex differences in mental disorder symptoms among Canadian police officers: the mediating role of social support, stress, and sleep quality

Police officers, and specifically women officers, report elevated mental disorder rates relative to the general population, which may be impacted by sleep quality, policing-related stress, and social support. In a sample of Canadian police officers, sex was indirectly related to post traumatic stress, depression, generalized anxiety, panic, and social anxiety symptoms through its relationships with social support and sleep quality, but not through policing-related stress. Sex was indirectly related to problematic alcohol use symptoms through sleep quality only. Differences in clinical symptom severity between both sexes may be partially accounted for by the worsened sleep quality reported by women officers relative to their men counterparts. Conversely, general social support appears to be a protective, albeit insufficient, factor influencing the mental health of women police officers. Male and women police officers did not differ in their reports of policing-related stress. The current results underscore the importance of incorporating strategies to improve sleep practices into police workplace environments. Additionally, findings that general social support and policing-related stress do not help explain the trend of increased clinical severity reported by women police suggest that more research is still needed to identify and delineate other contributing factors.

Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis

Background

Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited.

Objective

This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety.

Methods

The acceptability (uptake, participants’ characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches.

Results

A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges’ g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants’ characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%.

Conclusions

This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts.

Effects of passive music therapy on anxiety and vital signs in lung cancer patients undergoing peripherally inserted central catheter placement procedure

Purpose:

To evaluate the effects of passive music therapy on anxiety and vital signs among lung cancer patients at their first peripherally inserted central catheter placement procedure in China.

Methods:

A randomized controlled clinical trial was conducted in the cancer center of a hospital in Chengdu from May to December 2017. A total of 304 lung cancer patients who met the inclusion and exclusion criteria were recruited and randomly assigned to experimental ( n = 152) and control ( n = 152) group, respectively. The control group only received standard care, while the experimental group received standard care and passive music therapy during peripherally inserted central catheter placement (30–45 min) and after catheterization, until discharged from the hospital (twice a day, 30 min once). Measures include anxiety and vital signs (blood pressure, heart rate, and respiratory rate).

Results:

Repetitive measurement and analysis of variance showed that the patients in experimental group had a statistically significant decrease in anxiety, diastolic blood pressure, and heart rate over time compared to the control group, but no significant difference was identified in systolic blood pressure and respiratory rate.

Conclusion:

Passive music therapy can efficiently relieve the anxiety of lung cancer patients during peripherally inserted central catheter placement. It also can lower the patient’s diastolic blood pressure and slow down the heart rate. So, music therapy benefits patients with peripherally inserted central catheter.

Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study

BACKGROUND

Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care.

OBJECTIVE

The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns.

METHODS

Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years).

RESULTS

Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement.

CONCLUSIONS

Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care.

Supported Internet-Delivered Cognitive Behavior Treatment for Adults with Severe Depressive Symptoms: A Secondary Analysis

BACKGROUND

Depression is a highly prevalent mental health issue that exacts significant economic, societal, personal, and interpersonal costs. Innovative internet-delivered interventions have been designed to increase accessibility to and cost-effectiveness of treatments. These treatments have mainly targeted mild to moderate levels of depression. The increased risk associated with severe depression, particularly of suicidal ideation often results in this population being excluded from research studies. As a result, the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) in more severely depressed cohorts is less researched.

OBJECTIVE

The aim of this study is to examine the effect of iCBT on symptoms of severe depression, comorbid symptoms of anxiety, and levels of work and social functioning.

METHODS

Retrospective consent was provided by participants with elevated scores (>28 severe depression symptoms) on the Beck Depression Inventory (BDI-II) who accessed an iCBT intervention (Space from Depression) with support for up to 8 weeks. Data were collected at baseline, posttreatment, and 3-month follow-up on the primary outcome (BDI-II), and secondary outcomes (the Generalized Anxiety Disorder-7 and the Work and Social Adjustment Scale).

RESULTS

A significant change was observed on all measures between pre- and postmeasurement and maintained at 3-month follow-up. Clinical improvement was observed for participants on the BDI-II from pre- to postmeasurement, and suicidal ideation also reduced from pre- to postmeasurement.

CONCLUSIONS

Users of Space from Depression with symptoms of severe depression were found to have decreased symptoms of depression and anxiety and increased levels of work and social functioning. The intervention also demonstrated its potential to decrease suicidal ideation. Further investigation is required to determine why some individuals improve, and others do not. iCBT may have the potential to be used as an adjunct treatment for severe depression symptoms, but participants may require further treatment if they receive iCBT as a standalone intervention. Although promising, further research incorporating control groups is needed to support the utility of Space from Depression for use in or as an adjunct to treatment for severe depression.

Efficacy of online lifestyle interventions targeting lifestyle behaviour change in depressed populations: A systematic review

BACKGROUND

It is well established that depression and non-communicable diseases are highly co-morbid and bi-directional in nature. 'Lifestyle medicine' has recently gained traction in the field of psychiatry, aimed at improvement of both physical and mental health. Online interventions can be an effective and inexpensive alternative or supplement to therapy that is delivered using more traditional modes, overcoming barriers that may prohibit people from accessing treatment by promoting flexibility and accessibility.

METHODS

This systematic review evaluates the existing evidence for the efficacy or effectiveness of lifestyle interventions for (1) individuals with depressive symptoms, (2) clinically depressed populations or discussing the outcomes of depression within a subset of a larger cohort that are delivered online or via smart phone. Included studies were randomised controlled trials, with active comparator conditions, in adult populations and with reported lifestyle and depression-related outcomes. The analysis examined attrition, engagement, adherence and behaviour change techniques employed to achieve the target behaviours.

RESULTS

Seven studies were included in the review and targeted behaviour change in five domains: alcohol reduction, improved sleep quality/insomnia reduction, increased physical activity, reduced/cessation of substance abuse and smoking cessation. Four of the studies achieved significant improvements in the targeted behaviour; of these three also reported significant improvements in depressive symptoms. No studies reported significant improvements in depressive symptoms without a change in the target lifestyle behaviour.

CONCLUSION

The results of this review highlight the potential of online lifestyle interventions as adjunctive treatments for depression, and the possibility of achieving significant improvements in depressive symptoms when targeting lifestyle behaviour change.

Navigating the ethics of Internet-guided self-help interventions

Internet-guided self-help (IGSH) programs have proliferated recently to treat common mental health problems such as anxiety and depression. However, technology has outpaced the development of ethical guidelines for this mode of delivery. We examine ethical challenges in this new space, including defining the role "guides" play in treatment, crisis management, and user selection and screening. IGSH programs can provide safe and ethical care when they (a) coordinate care effectively with other systems; (b) provide competent and well-defined guidance; and (c) reach users that are appropriate for and well-educated about the services they are going to receive. We argue that jurisdictional practice constraints and outdated regulatory and ethical guidelines may impede the ability of IGSH programs to maintain or even improve performance when faced with greater demand, larger populations, heterogeneous settings, and the desire for large-scale dissemination.

Effectiveness, acceptability and feasibility of an Internet-delivered cognitive behavioral pain management program in a routine online therapy clinic in Canada

Background

Access to face-to-face cognitive behavioral pain management programs is very limited. Internet-delivered cognitive behavioral pain management has potential to improve client access to care but is not readily available in Canada.

Aims

The present study explored the effectiveness, acceptability, and feasibility of a previously validated Internet-delivered cognitive behavioral pain management course, the Pain Course, when offered in a publicly funded provincial Online Therapy Clinic. The five-lesson course was delivered over 8 weeks and was accompanied by brief weekly contact from a coach via weekly telephone calls and secure online messages.

Methods

A single-group open trial design (ISRCTN15509834) was employed (n = 55). Effectiveness was assessed by examining symptom measures at pretreatment, posttreatment, and 3-month follow-up. Completion rates and satisfaction ratings were used to examine acceptability. Feasibility was assessed by examining time required for service delivery.

Results

Results were highly comparable to past studies of the Pain Course showing improvements on primary measures of disability (Cohen’s d = 0.45; 18% reduction), depression (Cohen’s d = 0.85; 36% reduction), and anxiety (Cohen’s d = 0.52; 32% reduction) at posttreatment that were maintained at follow-up. Completion rates (76%) and course satisfaction ratings (85% would recommend course) were high. Coach time per week was estimated as M = 12.67 (SD = 6.53) min.

Conclusions

The findings add to existing literature on the Pain Course demonstrating for the first time the effectiveness, acceptability, and feasibility of Internet-delivered cognitive behavioral pain management programs for adults with chronic pain in a routine online therapy clinic.

Improving Implementation of eMental Health for Mood Disorders in Routine Practice: Systematic Review of Barriers and Facilitating Factors

BACKGROUND

Electronic mental health interventions (eMental health or eMH) can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care.

OBJECTIVE

This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice.

METHODS

A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice.

RESULTS

A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH.

CONCLUSIONS

Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients' mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The efficacy of aerobic exercise and resistance training as transdiagnostic interventions for anxiety-related disorders and constructs: A randomized controlled trial

Evidence supports exercise as an intervention for many mental health concerns; however, randomized controlled investigations of the efficacy of different exercise modalities and predictors of change are lacking. The purposes of the current trial were to: (1) quantify the effects of aerobic exercise and resistance training on anxiety-related disorder (including anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder) status, symptoms, and constructs, (2) evaluate whether both modalities of exercise were equivalent, and (3) to determine whether exercise enjoyment and physical fitness are associated with symptom reduction. A total of 48 individuals with anxiety-related disorders were randomized to aerobic exercise, resistance training, or a waitlist. Symptoms of anxiety-related disorders, related constructs, and exercise enjoyment were assessed at pre-intervention and weekly during the 4-week intervention. Participants were further assessed 1-week and 1-month post-intervention. Both exercise modalities were efficacious in improving disorder status. As well, aerobic exercise improved general psychological distress and anxiety, while resistance training improved disorder-specific symptoms, anxiety sensitivity, distress tolerance, and intolerance of uncertainty. Physical fitness predicted reductions in general psychological distress for both types of exercise and reductions in stress for aerobic exercise. Results highlight the efficacy of different exercise modalities in uniquely addressing anxiety-related disorder symptoms and constructs.

Preventing depression: Qualitatively examining the benefits of depression-focused iCBT for participants who do not meet clinical thresholds

•First qualitative study on the benefits of iCBT for those who do not meet clinical thresholds•Successful application of cognitive and behavioural strategies reported•Increased insight/awareness and improved self-efficacy reported•The format of online delivery was reported as helpful.•Findings align with previous face-to-face and iCBT treatments.

The implementation of guided Internet-based cognitive behaviour therapy for panic disorder in a routine-care setting: effectiveness and implementation efforts

Panic disorder is a common mental disorder. Guided Internet-based cognitive behavioural therapy (Guided Internet-based cognitive behaviour therapy (ICBT)) is a promising approach to reach more people in need of help. In the present effectiveness study, we investigated the outcome of guided ICBT for panic disorder after implementation in routine care. A total of 124 patients were included in the study, of which 114 started the treatment. Large within-group effect sizes were observed on the primary panic disorder symptoms (post-treatment: d = 1.24; 6-month follow-up: d = 1.39) and moderate and large effects on secondary panic disorder symptoms and depressive symptoms at post-treatment and follow-up (d = .55-1.13). More than half (56.1%) of the patients who started treatment recovered or improved at post-treatment. Among treatment takers (completed at least five of the nine modules), 69.9% recovered or improved. The effectiveness reported in the present trial is in line with previous effectiveness and efficacy trials of guided ICBT for panic disorder. This provides additional support for guided ICBT as a treatment alternative in routine care.

Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial

Fibromyalgia (FM) is a common and often debilitating chronic pain condition. Research shows that symptoms of depression and anxiety are present in up to three quarters of individuals with FM. Of concern, most adults with FM cannot access traditional face-to-face cognitive behavioural pain management programs, which are known to be beneficial. Given known difficulties with treatment access, the present study sought to explore the efficacy and acceptability of a previously developed Internet-delivered cognitive behavioural pain management course, the Pain Course, for adults with FM. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email, with a guide throughout the course. Participants were randomized either to the Pain Course (n = 30) or to a waiting-list control group (n = 30). Symptoms were assessed at pre-treatment, post-treatment and 4-week follow-up. Completion rates (87%) and satisfaction ratings (86%) were high. Improvements were significantly greater in treatment group participants compared to waiting-list group participants on measures of FM (Cohen's d =.70; 18% reduction), depression (Cohen's d =.63-.72; 20-28% reduction), pain (Cohen's d =.87; 11% improvement) and fear of pain (Cohen's d =1.61; 12% improvement). Smaller effects were also observed on measures of generalized anxiety and physical health. The changes were maintained at four-week follow-up. The current findings add to existing literature and highlight the specific potential of Internet-delivered cognitive behavioural pain management programs for adults with FM, especially as a part of stepped-care models of care. Future research directions are described.

Internet-based cognitive behavior therapy for major depressive disorder: A randomized controlled trial

BACKGROUND

Prior research has shown that the Sadness Program, a technician-assisted Internet-based cognitive behavioral therapy (iCBT) intervention developed in Australia, is effective for treating major depressive disorder (MDD). The current study aimed to expand this work by adapting the protocol for an American population and testing the Sadness Program with an attention control group.

METHODS

In this parallel-group, randomized controlled trial, adult MDD participants (18-45 years) were randomized to a 10-week period of iCBT (n = 37) or monitored attention control (MAC; n = 40). Participants in the iCBT group completed six online therapy lessons, which included access to content summaries and homework assignments. During the 10-week trial, iCBT and MAC participants logged into the web-based system six times to complete self-report symptom scales, and a nonclinician technician contacted participants weekly to provide encouragement and support. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), and the secondary outcomes were the Patient Health Questionnaire-9 and Kessler-10.

RESULTS

Intent-to-treat analyses revealed significantly greater reductions in depressive symptoms in iCBT compared with MAC participants, using both the self-report measures and the clinician-rated HRSD (d = -0.80). Importantly, iCBT participants also showed significantly higher rates of clinical response and remission. Exploratory analyses did not support illness severity as a moderator of treatment outcome.

CONCLUSIONS

The Sadness Program led to significant reductions in depression and distress symptoms. With its potential to be delivered in a scalable, cost-efficient manner, iCBT is a promising strategy to enhance access to effective care.

Differences in motivation and adherence to a prescribed assignment after face-to-face and online psychoeducation: an experimental study

Background

Adherence to treatment homework is associated with positive outcomes in behavioral psychotherapy but compliance to assignments is still often moderate. Whether adherence can be predicted by different types of motivation for the task and whether motivation plays different roles in face-to-face compared to online psychotherapy is unknown. If models of motivation, such as Self-determination theory, can be used to predict patients’ behavior, it may facilitate further research into homework promotion. The aims of this study were, therefore, to investigate whether motivation variables could predict adherence to a prescribed assignment in face-to-face and online interventions using a psychotherapy analog model.

Methods

A total of 100 participants were included in this study and randomized to either a face-to-face or online intervention. Participants in both groups received a psychoeducation session and were given an assignment for the subsequent week. The main outcome measurements were self-reported motivation and adherence to the assignment.

Results

Participant in the face-to-face condition reported significantly higher levels of motivation and showed higher levels of adherence compared to participants in the online condition. Adherence to the assignment was positively associated with intrinsic motivation and intervention credibility in the whole sample and especially in the online group.

Conclusions

This study shows that intrinsic motivation and intervention credibility are strong predictors of adherence to assignments, especially in online interventions. The results indicate that intrinsic motivation may be partly substituted with face-to-face contact with a therapist. It may also be possible to identify patients with low motivation in online interventions who are at risk of dropping out. Methods for making online interventions more intrinsically motivating without increasing external pressure are needed.

Trial registration

clinicaltrials.gov NCT02895308. Retrospectively registered 30 August 2016.

Attitudes towards digital treatment for depression: A European stakeholder survey

BACKGROUND

The integration of digital treatments into national mental health services is on the agenda in the European Union. The E-COMPARED consortium conducted a survey aimed at exploring stakeholders' knowledge, acceptance and expectations of digital treatments for depression, and at identifying factors that might influence their opinions when considering the implementation of these approaches.

METHOD

An online survey was conducted in eight European countries: France, Germany, Netherlands, Poland, Spain, Sweden, Switzerland and The United Kingdom. Organisations representing government bodies, care providers, service-users, funding/insurance bodies, technical developers and researchers were invited to participate in the survey. The participating countries and organisations reflect the diversity in health care infrastructures and e-health implementation across Europe.

RESULTS

A total of 764 organisations were invited to the survey during the period March-June 2014, with 175 of these organisations participating in our survey. The participating stakeholders reported moderate knowledge of digital treatments and considered cost-effectiveness to be the primary incentive for integration into care services. Low feasibility of delivery within existing care services was considered to be a primary barrier. Digital treatments were regarded more suitable for milder forms of depression. Stakeholders showed greater acceptability towards blended treatment (the integration of face-to-face and internet sessions within the same treatment protocol) compared to standalone internet treatments. Organisations in countries with developed e-health solutions reported greater knowledge and acceptability of digital treatments.

CONCLUSION

Mental health stakeholders in Europe are aware of the potential benefits of digital interventions. However, there are variations between countries and stakeholders in terms of level of knowledge about such interventions and their feasibility within routine care services. The high acceptance of blended treatments is an interesting finding that indicates a gradual integration of technology into clinical practice may fit the attitudes and needs of stakeholders. The potential of the blended treatment approach, in terms of enhancing acceptance of digital treatment while retaining the benefit of cost-effectiveness in delivery, should be further explored.

FUNDING

The E-COMPARED project has received funding from the European Union Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 603098.

Educating patients about Internet-delivered cognitive behaviour therapy: Perceptions among treatment seekers and non-treatment seekers before and after viewing an educational video

Internet-delivered cognitive behaviour therapy (ICBT) is an efficacious, yet novel approach to the treatment of depression and anxiety. It has the potential to improve access to evidenced-based care, but only if potential patients are aware of, understand, and have positive expectations about this treatment. In order to establish whether the use of an educational video could improve favourable expectations of ICBT, two studies were conducted. The goal of the first study was to determine whether an educational video would improve perceptions of ICBT among individuals seeking ICBT treatment and to determine what type of information (client testimonials versus statistical information related to outcomes) facilitates the greatest increase in positive expectations of ICBT. Participants who visited an ICBT service (N = 71) website were invited to first complete brief questionnaires assessing initial perceptions of ICBT. They were then randomly assigned to watch one of two videos containing either client testimonials (n = 32) or statistical information related to outcomes (n = 39). Patient perceptions of ICBT were then reassessed. Perceptions of ICBT were significantly higher post-video than pre-video and the type of information did not impact perceptions of ICBT. In the second study, the research was extended by examining perceptions of ICBT before and after watching an educational video (including both statistical and narrative information as this had no impact on perceptions) in a sample of individuals (N = 94) who were experiencing anxiety and depression but were not specifically seeking ICBT. As with treatment seekers, perceptions of ICBT were significantly higher post-video than pre-video. Comparison of the treatment and non-treatment seekers revealed no differences in perceptions of ICBT between the samples. The findings suggest that educational videos are an effective way to increase expectations of ICBT. Future directions for research are described.

The Implementation of Internet Interventions for Depression: A Scoping Review

BACKGROUND

Depression is one of the most common mental health problems among adults, but effective treatments are not widely accessible. The Internet holds promise as a cost-effective and convenient delivery platform of interventions for depression. However, studies suggest that Internet interventions are not widely available in routine settings.

OBJECTIVE

The aim of this study was to review the literature and examine whether there are systematic differences in reporting of the various implementation components on Internet interventions for depression, and then to examine what is known about and is characteristic of the implementation of these Internet interventions in regular care settings.

METHODS

We performed a scoping review, drawing upon a broad range of the literature on Internet interventions for depression in regular care, and used the active implementation framework to extract data.

RESULTS

Overall, the results suggested that knowledge about the implementation of Internet interventions for depression in regular care is limited. However, guided support from health professionals emphasizing program adherence and recruitment of end users to the interventions emerged as 2 main themes. We identified 3 additional themes among practitioners, including their qualifications, training, and supervision, but these were scarcely described in the literature. The competency drivers (ie, staff and user selection, training, and supervision) have received the most attention, while little attention has been given to organizational (ie, decision support, administration, and system intervention) and leadership drivers.

CONCLUSIONS

Research has placed little emphasis on reporting on the implementation of interventions in practice. Leadership and organizational drivers, in particular, have been largely neglected. The results of this scoping review have implications for future research and efforts to successfully implement Internet interventions for depression in regular care.

Transdiagnostic Internet-delivered cognitive behaviour therapy in Canada: An open trial comparing results of a specialized online clinic and nonspecialized community clinics

Effects of Internet-delivered cognitive behaviour therapy (ICBT) for anxiety and depression are not well understood when delivered in non-specialized as compared to specialized clinic settings. This open trial (n=458 patients) examined the benefits of transdiagnostic-ICBT when delivered in Canada by therapists (registered providers or graduate students) working in either a specialized online clinic or one of eight nonspecialized community clinics. Symptoms of depression and anxiety were assessed at pre-treatment, post-treatment and at 3-month follow-up. Completion rates and satisfaction were high. Significant and large reductions (effect sizes 1.17-1.31) were found on symptom measures. Completion rates, satisfaction levels and outcomes did not differ whether ICBT was delivered by therapists working in a specialized online clinic or nonspecialized community clinics. Differences were also not found between registered providers and graduate students, or therapists trained in psychology or another discipline. The findings support the public health potential of ICBT.

Internet-delivered Cognitive Behaviour Therapy for Depressive Symptoms: An Exploratory Examination of Therapist Behaviours and their Relationship to Outcome and Therapeutic Alliance

Background: A previous study of therapist-assisted Internet-delivered cognitive behaviour therapy (ICBT) for generalized anxiety (Paxling et al., 2013) identified eight distinct therapist behaviours in ICBT (task reinforcement, self-efficacy shaping, task prompting, alliance bolstering, psychoeducation, empathetic utterances, deadline flexibility, and self-disclosure). It is unknown how generalizable these behaviours are across ICBT programs. Aims: We systematically examined the frequency of these eight therapist behaviours and additional newly identified behaviours in e-mails sent to patients during the course of ICBT for depressive symptoms. We also conducted exploratory analyses to examine relationships between therapist behaviours, symptom improvement, and therapeutic alliance. Method: Data was obtained from a previously published open trial (Hadjistavropoulos et al., 2014). A total of 1013 e-mails sent from therapists (n = 24) to patients (n = 41) during ICBT for depressive symptoms were analyzed. Therapist behaviours were correlated with symptom change scores and ratings of therapeutic alliance at mid- and post-treatment. Results: Therapist behaviours described by Paxling et al. were reliably identified in the e-mails using qualitative content analysis; the frequencies of these behaviours differed, however, from the Paxling et al. study and three additional therapist behaviours were identified (administrative statements, questionnaire feedback, asking clarifying questions). Several therapist behaviours (e.g. administrative statements, task prompting) were associated with lower symptom improvement at post-treatment. Questionnaire feedback and task reinforcement were associated with higher patient ratings of therapeutic alliance. Conclusions: The study provides partial support for the generalizability of therapist-assistance across ICBT programs. Experimental research is needed to examine the impact of varying therapist-assistance on patient outcomes.

Effectiveness of blended depression treatment for adults in specialised mental healthcare: study protocol for a randomised controlled trial

BACKGROUND

Internet-based interventions are seen as an important potential strategy to improve accessibility and affordability of high quality treatments in mental healthcare. A growing number of studies have demonstrated the clinical efficacy of internet-based treatment for mood disorders, but scientific evidence for the application in routine specialised mental healthcare settings is limited. Also, little is known about the clinical and health-economic benefits of blended treatment, where online interventions are integrated with face-to-face treatment of depression in one treatment protocol. The primary aim of this study is to investigate the clinical and cost-effectiveness of blended Cognitive Behavioural Therapy (bCBT) for depression, as compared to treatment as usual (TAU) in specialised routine mental healthcare in the Netherlands. This trial is part of the E-COMPARED project which has a broader perspective, focussing on primary and specialised care in eight European countries.

METHODS/DESIGN

The study is a randomised controlled non-inferiority trial with two parallel conditions: bCBT and TAU. The blended treatment combines individual face-to-face CBT with CBT delivered through an Internet-based treatment platform (Moodbuster). This platform includes a mobile phone application, used for ecological momentary assessments, automated feedback and motivational messages. Weekly alternating face-to-face (10) and online (9) sessions will be delivered over a period of 19-20 weeks. TAU is defined as the routine care that subjects receive when they are diagnosed with depression in specialised mental healthcare. Adult patients ≥ 18 years old meeting DSM-IV diagnostic criteria for major depressive disorder will be recruited within participating outpatient specialised mental healthcare clinics in the Netherlands. Measurements will be taken at baseline and at 3, 6 and 12 months follow-up. The primary outcome will be depressive symptoms, measured with the PHQ-9 and QIDS. Secondary outcomes include health-related quality of life, mastery, treatment preference, working alliance, system usability, treatment satisfaction and possible negative side-effects. Moreover, a cost-effectiveness analysis will be conducted from a societal perspective and will include both direct and indirect healthcare costs.

DISCUSSION

The results of this study will provide insight into the health and economical outcomes of blended treatment for depression and give an indication of the value of implementing blended treatment in specialised clinical settings.

TRIAL REGISTRATION

Netherlands Trial Register NTR4962 . Registered 05-01-2015.

Therapeutic Alliance in Internet-Delivered Cognitive Behaviour Therapy for Depression or Generalized Anxiety

There has been limited research on therapeutic alliance in the context of therapist-assisted Internet-delivered cognitive behaviour therapy (ICBT) when delivered in clinical practice. The present study investigated therapeutic alliance in ICBT delivered to patients seeking treatment for symptoms of depression (n = 83) or generalized anxiety (n = 112) as part of an open dissemination trial. ICBT was provided by 27 registered therapists or 28 graduate students working in six geographically dispersed clinics; therapist-assistance was delivered primarily through secure messages and occasionally telephone calls. The Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were collected pre-, mid- and post-treatment, and the Therapeutic Alliance Questionnaire was assessed mid- and post-treatment. Therapeutic alliance ratings were high both at mid-treatment and post-treatment (above 80%). There was no relationship between therapeutic alliance ratings and improvement on primary outcomes. Among patients treated for depression, lower ratings of mid-treatment alliance were associated with concurrent treatment by a psychiatrist and fewer phone calls and emails from their therapist. Among patients treated for generalized anxiety, ratings of mid-treatment alliance were higher among registered providers as compared to graduate students. Multiple directions for future research on therapeutic alliance in ICBT are offered, including suggestions for developing a new measure of therapeutic alliance specific to ICBT and measuring therapeutic alliance throughout the treatment process. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

This research demonstrated that therapeutic alliance ratings were very strong at both mid- and post-treatment among patients who received Internet-delivered cognitive behaviour therapy (ICBT) for depression or anxiety in clinical practice. Among patients receiving ICBT for depression, lower ratings of therapeutic alliance were associated with patients reporting concurrent treatment by a psychiatrist and with the receipt of fewer phone calls and emails from the therapist. Among patients receiving ICBT for generalized anxiety, ratings of alliance were higher when patients were treated by registered providers as compared to graduate students. Therapeutic alliance ratings did not predict outcome in ICBT for depression or anxiety. Practitioners have reason to be confident that a therapeutic relationship can be formed in ICBT when delivered in clinical practice.

Predicting Response to Therapist-Assisted Internet-Delivered Cognitive Behavior Therapy for Depression or Anxiety Within an Open Dissemination Trial

Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) is efficacious for treating anxiety and depression, but predictors of response to treatment when delivered in clinical practice are not well understood. In this study, we explored demographic, clinical, and program variables that predicted modules started and symptom improvement (i.e., Generalized Anxiety Disorder-7 or Patient Health Questionnaire-9 total scores over pre-, mid-, and posttreatment) within a previously published open dissemination trial (Hadjistavropoulos et al., 2014). The sample consisted of 195 patients offered 12 modules of therapist-assisted ICBT for depression or generalized anxiety; ICBT was delivered by therapists working in six geographically dispersed clinics. Consistent across ICBT for depression or generalized anxiety, starting fewer modules was associated with more phone calls from therapists reflecting that therapists tended to call patients who did not start modules as scheduled. Also consistent for both ICBT programs, greater pretreatment condition severity and completion of more modules was associated with superior ICBT-derived benefit. Other predictors of response to treatment varied across the two programs. Younger age, lower education, taking psychotropic medication, being in receipt of psychiatric care and lower comfort with written communication were associated with either fewer program starts or lower symptom improvement in one of the two programs. It is concluded that monitoring response to ICBT may be particularly important in patients with these characteristics. Research directions for identifying patients who are less likely to benefit from ICBT are discussed.

Internet-Delivered Psychological Treatments

During the past 15 years, much progress has been made in developing and testing Internet-delivered psychological treatments. In particular, therapist-guided Internet treatments have been found to be effective for a wide range of psychiatric and somatic conditions in well over 100 controlled trials. These treatments require (a) a secure web platform, (b) robust assessment procedures, (c) treatment contents that can be text based or offered in other formats, and (d) a therapist role that differs from that in face-to-face therapy. Studies suggest that guided Internet treatments can be as effective as face-to-face treatments, lead to sustained improvements, work in clinically representative conditions, and probably are cost-effective. Despite these research findings, Internet treatment is not yet disseminated in most places, and clinical psychologists should consider using modern information technology and evidence-based treatment programs as a complement to their other services, even though there will always be clients for whom face-to-face treatment is the best option.

Quality of Smartphone Apps Related to Panic Disorder

Quality of smartphone apps related to panic: smartphone apps have a growing role in health care. This study assessed the quality of English-language apps for panic disorder (PD) and compared paid and free apps. Keywords related to PD were entered into the Google Play Store search engine. Apps were assessed using the following quality indicators: accountability, interactivity, self-help score (the potential of smartphone apps to help users in daily life), and evidence-based content quality. The Brief DISCERN score and the criteria of the "Health on the Net" label were also used as content quality indicators as well as the number of downloads. Of 247 apps identified, 52 met all inclusion criteria. The content quality and self-help scores of these PD apps were poor. None of the assessed indicators were associated with payment status or number of downloads. Multiple linear regressions showed that the Brief DISCERN score significantly predicted the content quality and self-help scores. Poor content quality and self-help scores of PD smartphone apps highlight the gap between their technological potential and the overall quality of available products.

Clinical Practice Models for the Use of E-Mental Health Resources in Primary Health Care by Health Professionals and Peer Workers: A Conceptual Framework

BACKGROUND

Research into e-mental health technologies has developed rapidly in the last 15 years. Applications such as Internet-delivered cognitive behavioral therapy interventions have accumulated considerable evidence of efficacy and some evidence of effectiveness. These programs have achieved similar outcomes to face-to-face therapy, while requiring much less clinician time. There is now burgeoning interest in integrating e-mental health resources with the broader mental health delivery system, particularly in primary care. The Australian government has supported the development and deployment of e-mental health resources, including websites that provide information, peer-to-peer support, automated self-help, and guided interventions. An ambitious national project has been commissioned to promote key resources to clinicians, to provide training in their use, and to evaluate the impact of promotion and training upon clinical practice. Previous initiatives have trained clinicians to use a single e-mental health program or a suite of related programs. In contrast, the current initiative will support community-based service providers to access a diverse array of resources developed and provided by many different groups.

OBJECTIVE

The objective of this paper was to develop a conceptual framework to support the use of e-mental health resources in routine primary health care. In particular, models of clinical practice are required to guide the use of the resources by diverse service providers and to inform professional training, promotional, and evaluation activities.

METHODS

Information about service providers' use of e-mental health resources was synthesized from a nonsystematic overview of published literature and the authors' experience of training primary care service providers.

RESULTS

Five emerging clinical practice models are proposed: (1) promotion; (2) case management; (3) coaching; (4) symptom-focused treatment; and (5) comprehensive therapy. We also consider the service provider skills required for each model and the ways that e-mental health resources might be used by general practice doctors and nurses, pharmacists, psychologists, social workers, occupational therapists, counselors, and peer workers.

CONCLUSIONS

The models proposed in the current paper provide a conceptual framework for policy-makers, researchers and clinicians interested in integrating e-mental health resources into primary care. Research is needed to establish the safety and effectiveness of the models in routine care and the best ways to support their implementation.