E-mailed standardized cognitive behavioural treatment of work-related stress: a randomized controlled trial

"Online, the counselor can't see me cry": a systematic literature review on emotion and computer-mediated care

Introduction

Computer-mediated care is becoming increasingly popular, but little research has been done on it and its effects on emotion-related outcomes. This systematic literature review aims to create an overview that addresses the research question: "Is there a relationship between computer-mediated care and emotional expression, perception, and emotional and (long-term) emotion outcomes?"

Method

This systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used five eligibility criteria, namely, (1) participants: adults seeking support; (2) intervention: eHealth; (3) diagnostic criteria: transdiagnostic concept of difficulty identifying, expressing, and/or regulating emotions (e.g., alexithymia); (4) comparator: either face-to-face care or no comparator; and (5) study design: quantitative studies or qualitative studies. Quality was assessed using the QualSyst tool.

Results

The analysis includes 25 research papers. Self-paced interventions appear to have a positive effect on emotion regulation. Videoconferencing interventions improved emotion regulation from before to after treatment but worsened emotion regulation compared with face-to-face treatment.

Discussion

The lack of variation in the modalities studied and the emotion measurements used make it difficult to draw responsible conclusions. Future research should examine how different modalities affect the real-time communication of emotions and how non-verbal cues influence this.

Improving Employee Mental Health Through an Internet-Based Job Crafting Intervention

Abstract: This article examined the impact of an online job crafting intervention (JCI) on employees’ ill-being and well-being at work, as measured by irritation and job satisfaction. To address this question, this study used an experimental design with randomized intervention and control groups. Recruited subjects ( N = 208) participated in a four-week web-based JCI, which consisted of one training session and three reflection sessions. The study outcomes were measured at three time points: before the intervention (premeasurement), a week after the intervention (postmeasurement), and four weeks after the intervention (follow-up measurement). The intervention led to a decline in irritation levels in the intervention group at both postmeasurement and follow-up measurement compared to the premeasurement and control group. No impact on job satisfaction was found. Web-based JCIs in the workplace provide the potential to alleviate symptoms of psychological malfunctioning.

Short-Term Magnesium Therapy Alleviates Moderate Stress in Patients with Fibromyalgia: A Randomized Double-Blind Clinical Trial

Patients suffering from fibromyalgia often report stress and pain, with both often refractory to usual drug treatment. Magnesium supplementation seems to improve fibromyalgia symptoms, but the level of evidence is still poor. This study is a randomized, controlled, double-blind trial in fibromyalgia patients that compared once a day oral magnesium 100 mg (Chronomag®, magnesium chloride technology formula) to placebo, for 1 month. The primary endpoint was the level of stress on the DASS-42 scale, and secondary endpoints were pain, sleep, quality of life, fatigue, catastrophism, social vulnerability, and magnesium blood concentrations. After 1 month of treatment, the DASS-42 score decreased in the magnesium and placebo groups but not significantly (21.8 ± 9.6 vs. 21.6 ± 10.8, respectively, p = 0.930). Magnesium supplementation significantly reduced the mild/moderate stress subgroup (DASS-42 stress score: 22.1 ± 2.8 to 12.3 ± 7.0 in magnesium vs. 21.9 ± 11.9 to 22.9 ± 11.9 in placebo, p = 0.003). Pain severity diminished significantly (p = 0.029) with magnesium while the other parameters were not significantly different between both groups. These findings show, for the first time, that magnesium improves mild/moderate stress and reduces the pain experience in fibromyalgia patients. This suggests that daily magnesium could be a useful treatment to improve the burden of disease of fibromyalgia patients and calls for a larger clinical trial.

Are Organizational EHealth Interventions Becoming More Effective at Addressing Employee Mental Health; A Systematic Review and Meta-Analysis (Preprint)

Background

Mental health conditions are considered the leading cause of disability, sickness absence, and long-term work incapacity. eHealth interventions provide employees with access to psychological assistance. There has been widespread implementation and provision of eHealth interventions in the workplace as an inexpensive and anonymous way of addressing common mental disorders.

Objective

This updated review aimed to synthesize the literature on the efficacy of eHealth interventions for anxiety, depression, and stress outcomes in employee samples in organizational settings and evaluate whether their effectiveness has improved over time.

Methods

Systematic searches of relevant articles published from 2004 to July 2020 of eHealth intervention trials (app- or web-based) focusing on the mental health of employees were conducted. The quality and bias of all studies were assessed. We extracted means and SDs from publications by comparing the differences in effect sizes (Hedge g) in standardized mental health outcomes. We meta-analyzed these data using a random-effects model.

Results

We identified a tripling of the body of evidence, with 75 trials available for meta-analysis from a combined sample of 14,747 articles. eHealth interventions showed small positive effects for anxiety (Hedges g=0.26, 95% CI 0.13-0.39; P<.001), depression (Hedges g=0.26, 95% CI 0.19-0.34; P<.001), and stress (Hedges g=0.25, 95% CI 0.17-0.34; P<.001) in employees’ after intervention, with similar effects seen at the medium-term follow-up. However, there was evidence of no increase in the effectiveness of these interventions over the past decade.

Conclusions

This review and meta-analysis confirmed that eHealth interventions have a small positive impact on reducing mental health symptoms in employees. Disappointingly, we found no evidence that, despite the advances in technology and the enormous resources in time, research, and finance devoted to this area for over a decade, better interventions are being produced. Hopefully, these small effect sizes do not represent optimum outcomes in organizational settings.

Trial Registration

PROSPERO CRD42020185859; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=185859

Occupational stress among Nigerian construction trade artisans in the building construction sector: An intervention study

BACKGROUND

Construction work can negatively affect artisans' mental health in the form of stress. This research investigated the effect of cognitive behavioral intervention on occupational stress among Nigerian construction trade artisans in the building construction sector.

METHODS

In this randomized controlled study involving 3 waves of data collection, 140 construction trade artisans who presented with high occupational stress symptoms at the study onset were assigned randomly to either a treatment condition (n = 70) or to a waitlist control condition (n = 70). The study involved pre-treatment and post-treatment assessments and a 3-months follow-up. The artisans' occupational stress questionnaire and artisans' dysfunctional thoughts at work scale were the data collection instruments.

RESULTS

Results revealed a significant effect of group on artisans' occupational stress and dysfunctional thoughts at work. Also, significant effects of time on artisans' occupational stress and dysfunctional thoughts at work were recorded. Finally, group × time interaction effects on artisans' occupational stress and dysfunctional thoughts at work were significant.

CONCLUSION

Cognitive behavioral intervention effectively reduced occupational stress symptoms and dysfunctional thoughts at work among Nigerian construction trade artisans compared with a waitlist control condition.

Effectiveness of a Smartphone App (BioBase) for Reducing Anxiety and Increasing Mental Well-Being: Pilot Feasibility and Acceptability Study

Background

The prevalence of workplace-related stress and anxiety is high, resulting in stress-related physical and mental illness. Digital self-guided interventions aimed at key areas of workplace design may be able to provide remote anxiolytic effects.

Objective

The aim of this feasibility study is to assess changes in anxiety and mental well-being after use of the BioBase programme, a mobile phone platform for psycho-educational modules, tools, and real-time feedback of physiological data.

Methods

A 4-week observational study was carried out in 55 healthy adults who were screened for stress with the Depression Anxiety Stress Scale (DASS) Stress subscale. Participants completed anxiety (6-item State-Trait Anxiety Inventory [STAI]) and mental well-being (Warwick-Edinburgh Mental Well-being Scale [WEMWBS]) questionnaires at baseline and at 4 weeks. Feedback questionnaires were administered after 4 weeks.

Results

After 4 weeks of using the programme and controlling for any effect of being paid to take part in the study, STAI significantly decreased (baseline mean 45.52 [SD 13.2]; 4-week mean 39.82 [SD 11.2]; t₅₄=–3.51; P<.001; CI –8.88 to –2.52; Cohen d=0.96) and WEMWBS significantly increased (baseline mean 48.12 [SD 6.4]; 4-week mean 50.4 [SD 6.9]; t₅₃=2.41; P=.019; CI 0.44-4.23; Cohen d=0.66). Further, higher baseline stress was significantly associated with a greater decrease in STAI (t₅₃=–3.41; P=.001; CI –8.10 to –2.10; R²=0.180) and a greater increase in WEMWBS (t₅₂=2.41; P=.019; CI 0.38-4.11, R²=0.101). On feedback, participants found the programme easy to use/navigate, with the content being acceptable and relevant to workplace-related stressors; 70% (21/30) of participants would recommend the programme to a friend.

Conclusions

The BioBase programme is a potentially effective intervention in decreasing anxiety and increasing mental well-being, with larger changes in those with higher baseline levels of stress.

Effects of a 6-Week Internet-Based Stress Management Program on Perceived Stress, Subjective Coping Skills, and Sleep Quality

Occupational stress management intervention programs are known to be effective in preventing stress-related health burden. Two essential mechanisms underlie this effect: (i) a reduction in perceived stress (e.g., via relaxation-oriented techniques), and (ii) an improvement in coping skills (e.g., via cognitive-behavioral interventions). While relaxation-oriented interventions are more frequently employed in occupational settings, cognitive-behavioral stress management interventions reveal stronger effects on stress-related outcomes. As an effective and economic strategy, the dissemination of stress management programs via the internet is soaring, but most internet-based programs focus on relaxation or reducing perceived stress. In the present study, we examined the effects of a self-guided, cognitive-behavioral 6-week Internet-Based Stress Management (IBSM) program on perceived stress, coping skills, emotional exhaustion, depressive symptoms, and sleep quality. The IBSM consists of six modules focusing on the improvement of stress management skills such as dealing with acute stress, building up resources, or reappraising stress-facilitating cognitions. The participants have to work through the content on a weekly basis, requiring about 30 min per week followed by a transfer task lasting another 30 min. Healthy employees reporting elevated stress were recruited over the Internet and then randomly assigned to the IBSM group or a waiting list control group. A total of 134 participants completed all assessments before and after the training or waiting period. The IBSM group reported lower subjective stress levels after the program than the control group. In addition, the IBSM group exhibited improved coping skills and better sleep quality. Emotional exhaustion was reduced in both groups, while depressive symptoms did not change. These results suggest that a brief, 6-week, cognitive-behavioral internet-based stress management program improves coping skills, sleep quality, and well-being, and reduces the perceived stress of employees. Our results might encourage large-scale studies on the long-term stability and clinical efficacy of internet-based programs. The trial is registered in the German Clinical Trials Register (DRKS00014837) URL. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014837.

Web-Based Intervention and Email-Counseling for Problem Gamblers: Results of a Randomized Controlled Trial

Web-based interventions have the potential to reduce the treatment gap for problem gambling. In the past years, several web-based help options were made available to the public. However, only few studies were conducted to test their effects. This study investigated the efficacy of two interventions for problem gamblers provided online by the German Federal Center for Health Education (BZgA). The first intervention is the guided program “Check Out” (CO), the second is email counselling (EC). A web-based randomized controlled trial with follow-up surveys after 3, 6 and 12 months was conducted. Participants were allocated to CO, to EC or to a waitlist (WL). Outcomes were the degree of problem gambling according to the Problem Gambling Severity Index, the number of days gambled in past 30 days, the highest stake during the past 30 days and the subjective well-being (WHO-5). 167 individuals were included in the trial. In comparison to the WL at the 3 months follow-up, participants of CO showed significant improvements with moderate to strong effect sizes in all outcomes. Strongest effects were found in the problem gambling severity (d = 0.91; p = 0.023), followed by the well-being (d = 0.70; p = 0.011), the gambling days (d = 0.59; p = 0.001) and the highest stake (d = 0.55; p = 0.012). Improvements were sustained until last follow-up. Compared to the WL, users of EC had beneficiary results in the problem gambling severity (d = 0.74; p = 0.022). No significant effect differences were found between CO and EC. However, according to process evaluation, users of CO reported a significantly stronger working alliance than users of EC (d = 0.70; p = 0.019) and used the intervention considerably longer (d = 0.84; p = 0.004). CO helps treatment-seeking individuals to sustainably reduce their gambling behavior and to increase their general well-being. Compared to EC, CO seems a better support option, since its effects include a wider range of outcomes. Possible reasons are the more engaging program structure and elements of CO, as well as the closer interaction between client and counselor.

Efficacy of an Internet-based intervention for job stress and burnout among medical professionals: study protocol for a randomized controlled trial

BACKGROUND

Medical professionals are at high risk of job stress and burnout. Research shows that work-related stress can be reduced through enhancing psychological resources, in particular, self-efficacy and perceived social support. These psychological resources can operate either individually or sequentially: in line with the cultivation hypothesis, self-efficacy precedes and cultivates perceived social support, whereas according to the enabling hypothesis it is perceived social support that comes first and enables self-efficacy. Based on this theoretical framework we developed an internet-based intervention, Med-Stress, dedicated to healthcare providers and aimed at reducing job stress and burnout. Med-Stress contains two modules that enhance self-efficacy and perceived social support, which are tested in four variants reflected in four study conditions. We expect that sequential enhancement of resources: self-efficacy and social support or social support and self-efficacy will yield larger posttest results than individual enhancement.

METHODS

In this four-arm randomized controlled trial we will test four variants of the Med-Stress intervention. The trial is open for professionally active medical providers aged at least 18 years (N = 1200) with access to an Internet-connected device. We will compare the effects of two experimental conditions reflecting cultivation and enabling effects of self-efficacy and perceived social support (sequential enhancement of resources), and two active controls strengthening self-efficacy or perceived social support. Job stress and job burnout will be the primary outcomes, whereas depression, job-related traumatic stress, and work engagement will be secondary ones. Additionally, we will measure perceived social support, self-efficacy to manage job stress and burnout, and the ability to obtain social support, exposure to traumatic events, and users' expectancy and credibility of the intervention. All assessments will be applied before the intervention, at posttest (at 3 or 6 weeks depending on the study condition), and at 6-month and 12-month follow up. In the case of experimental groups, additional measurements will be taken after enhancing each resource.

DISCUSSION

Resource-based interventions are relatively context-free and could potentially benefit medical professionals across the field. If Med-Stress is successful, its most effective variant could be implemented in the healthcare system as a standalone, supportive tool for employees.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03475290 Registered on 23 March 2018.

Indicated Prevention Interventions in the Workplace for Depressive Symptoms: A Systematic Review and Meta-analysis

CONTEXT

Depressive symptoms are highly prevalent and cause substantive morbidities and loss of functioning among employees. Depression may be prevented at its early stages. However, there is a paucity of information regarding indicated preventive interventions for depression among employees. The objective of this review is to examine the effectiveness of indicated interventions for the reduction of depressive symptoms in the workplace.

EVIDENCE ACQUISITION

A systematic review and meta-analysis of articles published between January 2000 and September 2017 was conducted using major electronic databases, including PubMed/MEDLINE, PsycINFO, EMBASE, SOCINDEX, and ABI/ProQuest. Studies were selected based on a set of predefined inclusion criteria. Primary outcome measures were depressive symptomatology, and the interventions were preventive in nature. Studies were pooled based on the intervention type and the effect size was measured using the standardized mean difference.

EVIDENCE SYNTHESIS

A computer and hand search of the literature yielded 4,462 papers, from which 16 trials were identified to be suitable for meta-analysis. Eight of 16 studies reported significant effects for workplace preventive interventions targeting depressive symptoms in which six were cognitive behavioral therapy (CBT)-based interventions and two were non-CBT-based interventions. Small to medium effect sizes were found for both CBT- and non-CBT-based interventions (standardized mean difference= -0.44, 95% CI= -0.61, -0.26, I²=62.1% and standardized mean difference= -0.32, 95% CI= -0.59, -0.06, I²=58%, respectively).

CONCLUSIONS

This review demonstrates that indicated interventions can significantly reduce the level of depressive symptoms among workers. The implementation of evidence-based workplace interventions should consequently be considered to prevent the development of depressive symptoms among employees.

Superiority of magnesium and vitamin B6 over magnesium alone on severe stress in healthy adults with low magnesemia: A randomized, single-blind clinical trial

INTRODUCTION

Animal and clinical studies suggest complementary effects of magnesium and high-dose pyridoxine (vitamin B6) on stress reduction. This is the first randomized trial evaluating the effects of combined magnesium and vitamin B6 supplementation on stress in a stressed population with low magnesemia using a validated measure of perceived stress.

METHODS

In this Phase IV, investigator-blinded trial (EudraCT: 2015-003749-24), healthy adults with Depression Anxiety Stress Scales (DASS-42) stress subscale score >18 and serum magnesium concentration 0.45 mmol/L-0.85 mmol/L, were randomized 1:1 to magnesium-vitamin B6 combination (Magne B6 [Mg-vitamin B6]; daily dose 300 mg and 30 mg, respectively) or magnesium alone (Magnespasmyl [Mg]; daily dose 300 mg). Outcomes included change in DASS-42 stress subscale score from baseline to Week 8 (primary endpoint) and Week 4, and incidence of adverse events (AEs).

RESULTS

In the modified intention-to-treat analysis (N = 264 subjects), both treatment arms substantially reduced DASS-42 stress subscale score from baseline to Week 8 (Mg-vitamin B6, 44.9%; Mg 42.4%); no statistical difference between arms was observed (p>0.05). An interaction (p = 0.0097) between baseline stress level and treatment warranted subgroup analysis (as per statistical plan); adults with severe/extremely severe stress (DASS-42 stress subscale score ≥25; N = 162) had a 24% greater improvement with Mg-vitamin B6 versus Mg at Week 8 (3.16 points, 95% CI 0.50 to 5.82, p = 0.0203). Consistent results were observed in the per protocol analysis and at Week 4. Overall, 12.1% of Mg-vitamin B6 treated and 17.4% of Mg-treated subjects experienced AEs potentially treatment related.

CONCLUSIONS

These findings suggest oral Mg supplementation alleviated stress in healthy adults with low magnesemia and the addition of vitamin B6 to Mg was not superior to Mg supplementation alone. With regard to subjects with severe/extremely severe stress, this study provides clinical support for greater benefit of Mg combined with vitamin B6.

Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta-analysis

Videoconferencing psychotherapy (VCP)-the remote delivery of psychotherapy via secure video link-is an innovative way of delivering psychotherapy, which has the potential to overcome many of the regularly cited barriers to accessing psychological treatment. However, some debate exists as to whether an adequate working alliance can be formed between therapist and client, when therapy is delivered through such a medium. The presented article is a systematic literature review and two meta-analyses aimed at answering the questions: Is working alliance actually poorer in VCP? And is outcome equivalence possible between VCP and face-to-face delivery? Twelve studies were identified which met inclusion/exclusion criteria, all of which demonstrated good working alliance and outcome for VCP. Meta-analyses showed that working alliance in VCP was inferior to face-to-face delivery (standardized mean difference [SMD] = -0.30; 95% confidence interval [CI] [-0.67, 0.07], p = 0.11; with the lower bound of the CI extending beyond the noninferiority margin [-0.50]), but that target symptom reduction was noninferior (SMD = -0.03; 95% CI [-0.45, 0.40], p = 0.90; CI within the noninferiority margin [0.50]). These results are discussed and directions for future research recommended.

Long-term effects of internet-supported cognitive behaviour therapy

INTRODUCTION

Internet-supported and therapist-guided cognitive behaviour therapy (ICBT) is effective for a range of problems in the short run, but less is known about the long-term effects with follow-ups of two years or longer. Areas covered: This paper reviews studies in which the long-term effects of guided ICBT were investigated. Following literature searches in PubMed and other sources meta-analytic statistics were calculated for 14 studies involving a total of 902 participants, and an average follow-up period of three years. Studies were from Sweden (n = 11) or the Netherlands (n = 3). Long-term outcome studies were found for panic disorder, social anxiety disorder, generalized anxiety disorder, depression, mixed anxiety and depression, obsessive-compulsive disorder, pathological gambling, stress and chronic fatigue. The duration of the treatments was usually short (8-15 weeks). The pre-to follow-up effect size was Hedge's g = 1.52, but with a significant heterogeneity. The average symptom improvement across studies was 50%. Treatment seeking in the follow-up period was not documented and few studies mentioned negative effects. Expert commentary: While effects may be overestimated, it is likely that therapist-supported ICBT can have enduring effects. Long-term follow-up data should be collected for more conditions and new technologies like smartphone-delivered treatments.

Long-Term Effectiveness of a Stress Management Intervention at Work: A 9-Year Follow-Up Study Based on a Randomized Wait-List Controlled Trial in Male Managers

Objective

Short- and medium-term effectiveness (up to 3 years) of individual level stress management interventions (SMI) at work were demonstrated, yet long-term effectiveness remains unexplored. We therefore aimed to address this research gap.

Methods

94 male middle managers participated in a randomized wait-list controlled trial between 2006 and 2008 and in a post-trial-follow-up survey in 2015. During the first two years, all received an 18-hour psychotherapeutic SMI intervention which was based on the Effort-Reward Imbalance (ERI) model: tackling stressor on mismatch between effort and reward and promoting recovery on overcommitment. Work stress (i.e., ERI indicators) was the primary outcome, and the secondary outcome was depressive symptoms. The long-term effectiveness of the SMI was examined by mixed modeling, using an external control group (n = 94).

Results

Effort and reward were substantially improved with significant intervention ⁎ time interaction effects (p < 0.001) compared to the external control group; effects on overcommitment and depressive symptoms were also significant (p < 0.05 and p < 0.01, resp.), though their trajectories in the intervention group were less sustainable.

Conclusions

The effectiveness of this psychotherapeutic SMI at work based on the ERI model was observed over a 9-year period, particularly on the effort-reward ratio.

Computer-based versus in-person interventions for preventing and reducing stress in workers

BACKGROUND

Chronic exposure to stress has been linked to several negative physiological and psychological health outcomes. Among employees, stress and its associated effects can also result in productivity losses and higher healthcare costs. In-person (face-to-face) and computer-based (web- and mobile-based) stress management interventions have been shown to be effective in reducing stress in employees compared to no intervention. However, it is unclear if one form of intervention delivery is more effective than the other. It is conceivable that computer-based interventions are more accessible, convenient, and cost-effective.

OBJECTIVES

To compare the effects of computer-based interventions versus in-person interventions for preventing and reducing stress in workers.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and two trials registers up to February 2017.

SELECTION CRITERIA

We included randomised controlled studies that compared the effectiveness of a computer-based stress management intervention (using any technique) with a face-to-face intervention that had the same content. We included studies that measured stress or burnout as an outcome, and used workers from any occupation as participants.

DATA COLLECTION AND ANALYSIS

Three authors independently screened and selected 75 unique studies for full-text review from 3431 unique reports identified from the search. We excluded 73 studies based on full-text assessment. We included two studies. Two review authors independently extracted stress outcome data from the two included studies. We contacted study authors to gather additional data. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to report study results. We did not perform meta-analyses due to variability in the primary outcome and considerable statistical heterogeneity. We used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

Two studies met the inclusion criteria, including a total of 159 participants in the included arms of the studies (67 participants completed computer-based interventions; 92 participants completed in-person interventions). Workers were primarily white, Caucasian, middle-aged, and college-educated. Both studies delivered education about stress, its causes, and strategies to reduce stress (e.g. relaxation or mindfulness) via a computer in the computer-based arm, and via small group sessions in the in-person arm. Both studies measured stress using different scales at short-term follow-up only (less than one month). Due to considerable heterogeneity in the results, we could not pool the data, and we analysed the results of the studies separately. The SMD of stress levels in the computer-based intervention group was 0.81 standard deviations higher (95% CI 0.21 to 1.41) than the in-person group in one study, and 0.35 standard deviations lower (95% CI -0.76 to 0.05) than the in-person group in another study. We judged both studies as having a high risk of bias.

AUTHORS' CONCLUSIONS

We found very low-quality evidence with conflicting results, when comparing the effectiveness of computer-based stress management interventions with in-person stress management interventions in employees. We could include only two studies with small sample sizes. We have very little confidence in the effect estimates. It is very likely that future studies will change these conclusions.

Improving Employee Well-Being and Effectiveness: Systematic Review and Meta-Analysis of Web-Based Psychological Interventions Delivered in the Workplace

Background

Stress, depression, and anxiety among working populations can result in reduced work performance and increased absenteeism. Although there is evidence that these common mental health problems are preventable and treatable in the workplace, uptake of psychological treatments among the working population is low. One way to address this may be the delivery of occupational digital mental health interventions. While there is convincing evidence for delivering digital psychological interventions within a health and community context, there is no systematic review or meta-analysis of these interventions in an occupational setting.

Objective

The aim of this study was to identify the effectiveness of occupational digital mental health interventions in enhancing employee psychological well-being and increasing work effectiveness and to identify intervention features associated with the highest rates of engagement and adherence.

Methods

A systematic review of the literature was conducted using Cochrane guidelines. Papers published from January 2000 to May 2016 were searched in the PsychINFO, MEDLINE, PubMed, Science Direct, and the Cochrane databases, as well as the databases of the researchers and relevant websites. Unpublished data was sought using the Conference Proceedings Citation Index and the Clinical Trials and International Standard Randomized Controlled Trial Number (ISRCTN) research registers. A meta-analysis was conducted by applying a random-effects model to assess the pooled effect size for psychological well-being and the work effectiveness outcomes. A positive deviance approach was used to identify those intervention features associated with the highest rates of engagement and adherence.

Results

In total, 21 randomized controlled trials (RCTs) met the search criteria. Occupational digital mental health interventions had a statistically significant effect post intervention on both psychological well-being (g=0.37, 95% CI 0.23-0.50) and work effectiveness (g=0.25, 95% CI 0.09-0.41) compared with the control condition. No statistically significant differences were found on either outcome between studies using cognitive behavioral therapy (CBT) approaches (as defined by the authors) compared with other psychological approaches, offering guidance compared with self-guidance, or recruiting from a targeted workplace population compared with a universal workplace population. In-depth analysis of the interventions identified by the positive deviance approach suggests that interventions that offer guidance are delivered over a shorter time frame (6 to 7 weeks), utilize secondary modalities for delivering the interventions and engaging users (ie, emails and text messages [short message service, SMS]), and use elements of persuasive technology (ie, self-monitoring and tailoring), which may achieve greater engagement and adherence.

Conclusions

This review provides evidence that occupational digital mental health interventions can improve workers’ psychological well-being and increase work effectiveness. It identifies intervention characteristics that may increase engagement. Recommendations are made for future research, practice, and intervention development.

Web-based interventions for the management of stress in the workplace: Focus, form, and efficacy

OBJECTIVES

This review sought to determine what is currently known about the focus, form, and efficacy of web-based interventions that aim to support the well-being of workers and enable them to manage their work-related stress.

METHOD

A scoping review of the literature as this relates to web-based interventions for the management of work-related stress and supporting the psychological well-being of workers was conducted.

RESULTS

Forty-eight web-based interventions were identified and reviewed, the majority of which (n = 37) were "individual" -focused and utilized cognitive-behavioral techniques, relaxation exercises, mindfulness, or cognitive behavior therapy. Most interventions identified were provided via a website (n = 34) and were atheoretical in nature.

CONCLUSIONS

There is some low-to-moderate quality evidence that "individual" -focused interventions are effective for supporting employee well-being and managing their work-related stress. There are few web-based interventions that target "organizational" or "individual/organization" interface factors, and there is limited support for their efficacy. A clear gap appears to exist between work-stress theory and its application in the design and development of web-based interventions for the management of work-related stress.

The Benefit of Web- and Computer-Based Interventions for Stress: A Systematic Review and Meta-Analysis

Background

Stress has been identified as one of the major public health issues in this century. New technologies offer opportunities to provide effective psychological interventions on a large scale.

Objective

The aim of this study is to investigate the efficacy of Web- and computer-based stress-management interventions in adults relative to a control group.

Methods

A meta-analysis was performed, including 26 comparisons (n=4226). Cohen d was calculated for the primary outcome level of stress to determine the difference between the intervention and control groups at posttest. Analyses of the effect on depression, anxiety, and stress in the following subgroups were also conducted: risk of bias, theoretical basis, guidance, and length of the intervention. Available follow-up data (1-3 months, 4-6 months) were assessed for the primary outcome stress.

Results

The overall mean effect size for stress at posttest was Cohen d=0.43 (95% CI 0.31-0.54). Significant, small effects were found for depression (Cohen d=0.34, 95% CI 0.21-0.48) and anxiety (Cohen d=0.32, 95% CI 0.17-0.47). Subgroup analyses revealed that guided interventions (Cohen d=0.64, 95% CI 0.50-0.79) were more effective than unguided interventions (Cohen d=0.33, 95% CI 0.20-0.46; P=.002). With regard to the length of the intervention, short interventions (≤4 weeks) showed a small effect size (Cohen d=0.33, 95% CI 0.22-0.44) and medium-long interventions (5-8 weeks) were moderately effective (Cohen d=0.59; 95% CI 0.45-0.74), whereas long interventions (≥9 weeks) produced a nonsignificant effect (Cohen d=0.21, 95% CI –0.05 to 0.47; P=.006). In terms of treatment type, interventions based on cognitive behavioral therapy (CBT) and third-wave CBT (TWC) showed small-to-moderate effect sizes (CBT: Cohen d=0.40, 95% CI 0.19-0.61; TWC: Cohen d=0.53, 95% CI 0.35-0.71), and alternative interventions produced a small effect size (Cohen d=0.24, 95% CI 0.12-0.36; P=.03). Early evidence on follow-up data indicates that Web- and computer-based stress-management interventions can sustain their effects in terms of stress reduction in a small-to-moderate range up to 6 months.

Conclusions

These results provide evidence that Web- and computer-based stress-management interventions can be effective and have the potential to reduce stress-related mental health problems on a large scale.

Effects of web-based stress and depression literacy intervention on improving work engagement among workers with low work engagement: An analysis of secondary outcome of a randomized controlled trial

Objective:

The purpose of this randomized, controlled trial was to examine the effects of a psychoeducational information website on improving work engagement among individual workers with low work engagement, where work engagement was measured as a secondary outcome.

Methods:

Participants were recruited from registered members of a web survey site in Japan. Participants who fulfilled the eligibility criteria were randomly allocated to intervention or control groups. Immediately after the baseline survey, the intervention group was invited to study a psychoeducational website called the "UTSMed," which provided general mental health literacy and cognitive behavioral skills. Work engagement was assessed by using the Utrecht Work Engagement Scale at baseline, 1-, and 4-month follow-ups for both intervention and control groups. An exploratory analysis was conducted for a subgroup with low (lower than the median scores) work engagement scores at baseline.

Results:

A total of 1,236 workers completed the baseline survey. In the low work engagement subgroup, a total of 313 and 300 participants were allocated to an intervention and control group, respectively. In the high work engagement subgroup, 305 and 318 participants were allocated to an intervention and control group, respectively. The program showed a significant effect on work engagement (t = 1.98, P = 0.048) at the 4-month follow-up in the low work engagement subgroup, with a small effect size (d = 0.17).

Conclusion:

A web-based psychoeducation resource of mental health literacy and cognitive behavioral skills may be effective for improving work engagement among individual workers with low work engagement.

Efficacy of an internet-based intervention for burnout: a randomized controlled trial in the German working population

BACKGROUND AND OBJECTIVES

Internet-based interventions are a viable treatment option for various mental problems. However, their effects on the burnout syndrome yielded mixed results. In this paper, we examine the efficacy of a structured and therapist-guided internet intervention, based on solution-focused and cognitive-behavioral therapy, for individuals with symptoms of burnout.

DESIGN

Two-arm, Internet-based, randomized, wait-list controlled trial (RCT).

METHODS

Participants were recruited through in-house events and online advertising. They were randomly assigned to the intervention or a wait-list. Group comparison was conducted three months after randomization. Outcomes were the burnout level according to the Maslach Burnout Inventory (MBI-GS) and the levels of depression, anxiety and stress according to the DASS-21.

RESULTS

Thirty-nine participants were included in the trial; 36 (92.3%) took part at the 3-months-follow-up. Intention-to-treat analyses revealed significant group differences in favor of the intervention group in depression (d = 0.66), cynicism (d = 0.87) and personal accomplishment (d = 0.75).

CONCLUSIONS

The intervention helped ameliorate symptoms of work-related stress and burnout. Although limited by a small sample size, the study suggests that the program provides effective support for affected individuals. However, further studies with bigger sample sizes should be conducted to examine the effects of such programs more precisely.

Using smartphone-based applications (apps) in workplace health promotion: The opinion of German and Austrian leaders

Reaching the actual target group for a web-based health promotion project turns out to be a difficult task. In this article, individual and organizational factors which can influence the decision of using apps in workplace health promotion are analyzed. Furthermore, we analyzed the opinion about feedback possibilities of apps in workplace health promotion. A study with 438 leaders was conducted, as leaders can be seen as a key factor in the success of health promotion projects. The results showed that younger leaders and leaders with a more positive attitude toward workplace health promotion are more likely to use an app. Furthermore, leaders with a positive attitude are more interested in expert-feedback than in instant feedback received from an app.

Adherence to Internet-Based Mobile-Supported Stress Management: A Pooled Analysis of Individual Participant Data From Three Randomized Controlled Trials

Background

Nonadherence to treatment is a prevalent issue in Internet interventions. Guidance from health care professionals has been found to increase treatment adherence rates in Internet interventions for a range of physical and mental disorders. Evaluating different guidance formats of varying intensity is important, particularly with respect to improvement of effectiveness and cost-effectiveness. Identifying predictors of nonadherence allows for the opportunity to better adapt Internet interventions to the needs of participants especially at risk for discontinuing treatment.

Objective

The goal of this study was to investigate the influence of different guidance formats (content-focused guidance, adherence-focused guidance, and administrative guidance) on adherence and to identify predictors of nonadherence in an Internet-based mobile-supported stress management intervention (ie, GET.ON Stress) for employees.

Methods

The data from the groups who received the intervention were pooled from three randomized controlled trials (RCTs) that evaluated the efficacy of the same Internet-based mobile-supported stress management intervention (N=395). The RCTs only differed in terms of the guidance format (content-focused guidance vs waitlist control, adherence-focused guidance vs waitlist control, administrative guidance vs waitlist control). Adherence was defined by the number of completed treatment modules (0-7). An ANOVA was performed to compare the adherence rates from the different guidance formats. Multiple hierarchical linear regression analysis was conducted to evaluate predictors of nonadherence, which included gender, age, education, symptom-related factors, and hope for improvement.

Results

In all, 70.5% (93/132) of the content-focused guidance sample, 68.9% (91/132) of the adherence-focused guidance sample, and 42.0% (55/131) of the participants in the administrative guidance sample completed all treatment modules. Guidance had a significant effect on treatment adherence (F_2,392=11.64, P<.001; ω²=.05). Participants in the content-focused guidance (mean 5.70, SD 2.32) and adherence-focused guidance samples (mean 5.58, SD 2.33) completed significantly more modules than participants in the administrative guidance sample (mean 4.36, SD 2.78; t₂₂₃=4.53, P<.001; r=.29). Content-focused guidance was not significantly associated with higher adherence compared to adherence-focused guidance (t₂₆₂=0.42, P=.67; r=.03). The effect size of r=.03 (95% CI –0.09 to 0.15) did not pass the equivalence margin of r=.20 and the upper bound of the 95% CI lay below the predefined margin, indicating equivalence between adherence-focused guidance and content-focused guidance. Beyond the influence of guidance, none of the predictors significantly predicted nonadherence.

Conclusions

Guidance has been shown to be an influential factor in promoting adherence to an Internet-based mobile-supported stress management intervention. Adherence-focused guidance, which included email reminders and feedback on demand, was equivalent to content-focused guidance with regular feedback while requiring only approximately a quarter of the coaching resources. This could be a promising discovery in terms of cost-effectiveness. However, even after considering guidance, sociodemographic, and symptom-related characteristics, most interindividual differences in nonadherence remain unexplained.

Clinical Trial

DRKS00004749; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL _ID=DRKS00004749 (Archived by WebCite at http://www.webcitation.org/6QiDk9Zn8); DRKS00005112; http://drks-neu.uniklinik-freiburg. de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005112 (Archived by WebCite at http://www.webcitation.org/6QiDysvev); DRKS00005384; http://drks-neu.uniklinik-freiburg.de/ drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005384 (Archived by WebCite at http://www.webcitation.org/6QiE0xcpE)

The effectiveness of email-based exercises in promoting psychological wellbeing and healthy lifestyle: a two-year follow-up study

Background

Web-based interventions provide a possibility to enhance well-being in large groups of people. Only a few studies have studied the effectiveness of the interventions and there is no information on the sustainability of the effects. Study aims were to investigate both the short (2-month) and long-term (2-year) effects of email-based training for mental health and lifestyle.

Methods

Persons who completed an ‘Electronic Health Check’, as advertised in a TV program, were offered a chance to participate in email-based interventions. The baseline questionnaire was completed by 73 054 people, with 42 761 starting interventions, and 16 499 people participating in at least one of the follow-ups. Persons who did not choose to start the interventions served as controls.

Results

At baseline, the intervention group had a higher level of stress and lower gratitude and confidence in the future than the control group. Both groups showed improvement in the level of stress, but improvement was more marked in the intervention group (P < .001 for both time points). In confidence in the future and gratitude, people who chose interpersonal interventions showed significant improvements at both time points (P < .001), whereas those choosing lifestyle interventions showed improvement only at the 2-month follow-up. Participants who had done the exercises according to instructions had the most sustained improvements in measures of psychological health at the 2-year follow-up. As for lifestyle, people who had started lifestyle interventions increased their exercise (P < .001 at both time points).

Conclusions

Internet-based interventions are feasible for mental health promotion and should be available for people interested in improving their psychological well-being and lifestyle.

Electronic supplementary material

The online version of this article (doi:10.1186/s40359-016-0125-4) contains supplementary material, which is available to authorized users.

[Interest of computer-based cognitive behavioral stress management. Feasability of the Seren@ctif program]

INTRODUCTION

Cognitive-behavioural stress management programs have been studied in many countries. Many reports have shown beyond a doubt their efficacy to reduce perceived stress, anxiety symptoms and to improve quality of life of patients. Considering the very large number of people who could benefit from such programs but are unable to reach them, self-help programs have been offered. First presented as books (bibliotherapy), these programs then became enriched by computing and digital supports. Regrettably, many of the programs of stress management based on the Cognitive behavioural therapy (CBT) both in face-to-face and on digital support have been little evaluated in France. To our knowledge, the Seren@ctif program is the first French language self-help program of stress management proposed on digital support.

AIM OF THE STUDY

We led a feasibility study of this program on 10 patients responding to the diagnosis of adjustment disorder with anxiety according to the DSM IV criteria.

METHODS

The program includes 5 weekly sessions that the patient follows in our unit from a web site. He benefits from minimal contact with a medical member of staff before and after every session. Right from the first session an USB key is supplied to the patient containing videos, audio files, self-help book portfolio in the form of an e-guide, and log books with the exercises to be realized between each sessions of the 5 session program. The patient is encouraged to practice 20 minutes of exercises 5 or 6 days per week. The program's feasibility has been assessed in accordance with a standard satisfaction scale. Anxiety symptomatology has been quantified thanks to the Spielberger State-Trait Anxiety Inventory (STAI-Y-S).

RESULTS

After the scheduled 5 weeks, good results were found in terms of acceptability and attractiveness. The average score to the satisfaction survey was at least equal to 4 out of 5 for each item. The mean score on the STAI-State decreased from 53,4 (SD: 8,29) to 44,2 (SD: 7,73) following the intervention.

DISCUSSION

The Seren@ctif program may be useful within the framework of a psychoeducative approach. It could also be advised for people suffering from anxiety related to stress. Soon, the program will be tested on patients with usual care suffering from adjustment disorder with anxiety in order to precisely assess its benefits.

Self-guided internet-based and mobile-based stress management for employees: results of a randomised controlled trial

OBJECTIVE

This randomised controlled trial (RCT) aimed to evaluate the efficacy of a self-guided internet-based stress management intervention (iSMI) for employees compared to a 6-month wait-list control group (WLC) with full access for both groups to treatment as usual.

METHOD

A sample of 264 employees with elevated symptoms of perceived stress (Perceived Stress Scale, PSS-10 ≥22) was randomly assigned to either the iSMI or to the WLC. The iSMI consisted of seven sessions and one booster session including problem-solving and emotion regulation techniques. Self-report data were assessed at baseline, at 7 weeks and at 6 months following randomisation. The primary outcome was perceived stress (PSS-10). The secondary outcomes included other relevant mental-related and work-related health outcomes. Data were analysed based on intention-to-treat principles.

RESULTS

The iSMI participants showed a significantly higher reduction in perceived stress from baseline to post-treatment at 7 weeks (d=0.96, 95% CI 0.70 to 1.21) and to the 6-month follow-up (d=0.65, 95% CI 0.40 to 0.89) compared to the WLC. Significant differences with small to moderate effect sizes were also found for depression, anxiety, emotional exhaustion, sleeping problems, worrying, mental health-related quality of life, psychological detachment, emotion regulation skills and presenteeism, in favour of the experimental group. At the 6 -month follow-up, all outcomes remained significantly better for the experimental group with the exception of work engagement, physical health-related quality of life and absenteeism, which were not found to significantly differ between the iSMI and WLC groups.

CONCLUSIONS

The iSMI investigated in this study was found to be effective in reducing typical mental-related and work-related health symptoms of stressed employees. Internet-based self-guided interventions could be an acceptable, effective and potentially cost-effective approach to reduce the negative consequences associated with work-related stress.

Effects of a Web-Based Intervention for Stress Reduction in Primary Care: A Cluster Randomized Controlled Trial

BACKGROUND

Preliminary findings suggest that Web-based interventions may be effective in achieving significant stress reduction. To date, there are no findings available for primary care patients. This is the first study that investigates a Web-based intervention for stress reduction in primary care.

OBJECTIVE

The aim was to examine the short-term effectiveness of a fully automated Web-based coaching program regarding stress reduction in a primary care setting.

METHODS

The study was an unblinded cluster randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily text message reminders, and weekly feedback through the Internet. All components of the program were fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was change in the Perceived Stress Questionnaire (PSQ) over 12 weeks.

RESULTS

A total of 93 participants (40 in intervention group, 53 in control group) were recruited into the study. For 25 participants from the intervention group and 49 participants from the control group, PSQ scores at baseline and 12 weeks were available. In the intention-to-treat analysis, the PSQ score decreased by mean 8.2 (SD 12.7) in the intervention group and by mean 12.6 (SD 14.7) in the control group. There was no significant difference identified between the groups (mean difference -4.5, 95% CI -10.2 to 1.3, P=.13).

CONCLUSIONS

This trial could not show that the tested Web-based intervention was effective for reducing stress compared to usual care. The limited statistical power and the high dropout rate may have reduced the study's ability to detect significant differences between the groups. Further randomized controlled trials are needed with larger populations to investigate the long-term outcome as well as the contents of usual primary care.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00003067; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?=DRKS00003067 (Archived by WebCite at http://www.webcitation.org/6eXk0PXmO).

Web-Based and Mobile Stress Management Intervention for Employees: A Randomized Controlled Trial

Background

Work-related stress is highly prevalent among employees and is associated with adverse mental health consequences. Web-based interventions offer the opportunity to deliver effective solutions on a large scale; however, the evidence is limited and the results conflicting.

Objective

This randomized controlled trial evaluated the efficacy of guided Web- and mobile-based stress management training for employees.

Methods

A total of 264 employees with elevated symptoms of stress (Perceived Stress Scale-10, PSS-10≥22) were recruited from the general working population and randomly assigned to an Internet-based stress management intervention (iSMI) or waitlist control group. The intervention (GET.ON Stress) was based on Lazarus’s transactional model of stress, consisted of seven sessions, and applied both well-established problem solving and more recently developed emotion regulation strategies. Participants also had the opportunity to request automatic text messages on their mobile phone along with the iSMI. Participants received written feedback on every completed session from an e-coach. The primary outcome was perceived stress (PSS-10). Web-based self-report assessments for both groups were scheduled at baseline, 7 weeks, and 6 months. At 12 months, an extended follow-up was carried out for the iSMI group only.

Results

An intention-to-treat analysis of covariance revealed significantly large effect differences between iSMI and waitlist control groups for perceived stress at posttest (F_1,261=58.08, P<.001; Cohen’s d=0.83) and at the 6-month follow-up (F_1,261=80.17, P<.001; Cohen’s d=1.02). The effects in the iSMI group were maintained at 12-month follow-up.

Conclusions

This Web- and mobile-based intervention has proven effective in reducing stress in employees in the long term. Internet-based stress management interventions should be further pursued as a valuable alternative to face-to-face interventions.

Trial Registration

German Clinical Trials Register (DRKS): 00004749; http://drks-neu.uniklinik-freiburg.de/ drks_web/setLocale_EN.do (Archived by WebCite at http://www.webcitation.org/6e8rl98nl)

Does Internet-based cognitive behavioral therapy (iCBT) prevent major depressive episode for workers? A 12-month follow-up of a randomized controlled trial

BACKGROUND

In this study we investigated whether an Internet-based computerized cognitive behavioral therapy (iCBT) program can decrease the risk of DSM-IV-TR major depressive episodes (MDE) during a 12-month follow-up of a randomized controlled trial of Japanese workers.

METHOD

Participants were recruited from one company and three departments of another company. Those participants who did not experience MDE in the past month were randomly allocated to intervention or control groups (n = 381 for each). A 6-week, six-lesson iCBT program was provided to the intervention group. While the control group only received the usual preventive mental health service for the first 6 months, the control group was given a chance to undertake the iCBT program after a 6-month follow-up. The primary outcome was a new onset of DSM-IV-TR MDE during the 12-month follow-up, as assessed by means of the web version of the WHO Composite International Diagnostic Interview (CIDI), version 3.0 depression section.

RESULTS

The intervention group had a significantly lower incidence of MDE at the 12-month follow-up than the control group (Log-rank χ2 = 7.04, p < 0.01). The hazard ratio for the intervention group was 0.22 (95% confidence interval 0.06-0.75), when estimated by the Cox proportional hazard model.

CONCLUSIONS

The present study demonstrates that an iCBT program is effective in preventing MDE in the working population. However, it should be noted that MDE was measured by self-report, while the CIDI can measure the episodes more strictly following DSM-IV criteria.

Effectiveness, Mediators, and Effect Predictors of Internet Interventions for Chronic Cancer-Related Fatigue: The Design and an Analysis Plan of a 3-Armed Randomized Controlled Trial

Background

Internet interventions offer advantages that especially cancer survivors who suffer from fatigue could benefit from. Given the growing number of such patients, Internet interventions could supplement and strengthen currently available health care.

Objective

This paper describes the design and analysis plan that will be used to study 2 Internet interventions aimed at reducing severe fatigue in cancer survivors: a mobile ambulant activity feedback therapy supported through a weekly email by a physiotherapist and a weekly Web- and mindfulness-based cognitive therapy supported online by a psychologist. The data resulting from this trial will be used to (1) investigate the effectiveness, (2) investigate potential mediators of these interventions, and (3) explore participant characteristics that can predict the effect of these interventions.

Methods

A 3-armed randomized controlled trial is proposed that compares both Internet interventions with an active control condition that solely consists of receiving psycho-educational emails. The intervention period is 9 weeks for all 3 conditions. Six months after baseline, participants in the control condition can choose to follow 1 of the 2 experimental Internet interventions. Outcomes are measured in terms of fatigue severity, mental health, and self-perceived work ability. All are Web-assessed at baseline, 2 weeks after the intervention period, and at 6 and 12 months after baseline. Fatigue severity, mindfulness, physical activity, expectations and credibility of the intervention, therapeutic working alliance, sleep quality, and sense of control over fatigue are assessed 3 times during the intervention period for identifying mediators of the interventions. Recruitment is performed nationally throughout the Netherlands through patient organizations and their websites, newspapers, and by informing various types of health professionals. All participants register at an open-access website. We aim at including 330 cancer survivors who have finished curative-intent cancer treatment at least 3 months previously, and have been suffering from severe fatigue ever since. All cancer types are included. A detailed analysis plan is described to address the research questions, which allows for individual variation, and fully exploits the longitudinal design.

Results

Recruitment started in April 2013 and will proceed until April 2015.

Conclusions

This paper describes a systematic trial design for studying 2 different interventions for chronic cancer-related fatigue in order to gain insight into the effectiveness and mediators of the interventions. This design will also be used to identify predictors for the interventions’ effect on fatigue. By publishing our hypotheses and analysis plan before completion of data collection, this paper is a first step in reporting on this trial comprehensively.

Trial Registration

The Netherlands National Trial Register (NTR3483). (Archived by WebCite at http://www.webcitation.org/6NWZqon3o).

Establishing guidelines for executing and reporting Internet intervention research

The field of Internet interventions is growing rapidly. New programs are continually being developed to facilitate health and mental health promotion, disease and emotional distress prevention, risk factor management, treatment, and relapse prevention. However, a clear definition of Internet interventions, guidelines for research, and evidence of effectiveness have been slower to follow. This article focuses on the quality standardization of research on Internet-delivered psychological and behavioural interventions. Although the science underpinning Internet interventions is just starting to be established, across research studies there are often conceptual and methodological difficulties. The authors argue that this situation is due to the lack of universally accepted operational guidelines and evaluation methods. Following a critical appraisal of existing codes of conduct and guidelines for Internet-assisted psychological and health interventions, the authors developed a framework of guidelines for Internet intervention research utilizing aspects of facet theory (Guttman & Greenbaum, 1998). The framework of facets, elements, and guidelines of best practice in reporting Internet intervention research was then sent to several leading researchers in the field for their comment and input, so that a consensus framework could be agreed on. The authors outline 12 key facets to be considered when evaluating and reporting Internet intervention studies. Each facet consists of a range of recommended elements, designed as the minimum features for reporting Internet intervention studies. The authors propose that this framework be utilized when designing and reporting Internet intervention research, so results across studies can be replicated, extended, compared, and contrasted with greater ease and clarity.

Effects of an internet-based cognitive behavioural therapy intervention on preventing major depressive episodes among workers: a protocol for a randomised controlled trial

INTRODUCTION

The aim of this study is to examine the effects of an internet-based cognitive behavioural therapy (iCBT) program on decreasing the risk of major depressive episodes (MDEs) among workers employed in a private corporate group in Japan, using a randomised controlled trial design.

METHODS AND ANALYSIS

All of the workers in a corporate group (n=20,000) will be recruited through an invitation email. Participants who fulfil the inclusion criteria will be randomly allocated to intervention or control groups (planned N=4050 for each group). They will be allowed to complete the six lessons of the iCBT program within 10 weeks after the baseline survey. Those in the control group will receive the same iCBT after 12 months. The program includes several CBT skills: self-monitoring, cognitive restructuring, assertiveness, problem-solving and relaxation. The primary outcome measure is no new onset of MDE (using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)/DSM-5 criteria) during the 12-month follow-up. Assessment will use the web version of the WHO Composite International Diagnostic Interview V.3.0 depression section.

ETHICS AND DISSEMINATION

The Research Ethics Review Board of Graduate School of Medicine, the University of Tokyo (No. 3083-(2)), approved the study procedures.

TRIAL REGISTRATION NUMBER

The study protocol is registered at the UMIN Clinical Trials Registry (UMIN-CTR; ID=UMIN000014146).

Collateral outcomes in e-mental health: a systematic review of the evidence for added benefits of computerized cognitive behavior therapy interventions for mental health

BACKGROUND

E-mental health is a growing research field and an increasing number of computerized cognitive behavior therapy (cCBT) interventions are available for numerous mental health issues. Such interventions are often claimed to have added benefits, or collateral outcomes, when compared with traditional delivery platforms. Our aim was to systematically review the evidence of the cost-effectiveness, geographic flexibility, time flexibility, waiting time for treatment, stigma, therapist time, effects on help-seeking and treatment satisfaction of cCBT interventions for mental health.

METHOD

The electronic databases Medline and Web of Science were searched for peer-reviewed controlled trials investigating collateral outcomes in computerized and internet-based CBT.

RESULTS

The literature search identified 101 published papers (95 studies), which were included in this review. The results suggest that cCBT interventions are cost-effective and often cheaper than usual care. Limited evidence was found with regard to geographic flexibility, time flexibility, waiting time for treatment, stigma and the effects on help-seeking. Personal support in cCBT was found to take many forms, was not limited only to therapists, and seemed to increase treatment adherence and reduce attrition. Treatment satisfaction with cCBT was found to be high, but more research on attrition due to dissatisfaction is required.

CONCLUSIONS

Although the results of this systematic review on the collateral outcomes provide support for the potential of cCBT, these outcomes need to be better assessed within individual e-mental health studies.

Efficacy and cost-effectiveness of minimal guided and unguided internet-based mobile supported stress-management in employees with occupational stress: a three-armed randomised controlled trial

Background

Internet- and mobile based stress-management interventions (iSMI) may be an effective means to address the negative consequences of occupational stress. However, available results from randomised controlled trials are conflicting. Moreover, it is yet not clear whether guided or unguided self-help iSMI provide better value for money. Internet-based mental health interventions without guidance are often much less effective than interventions including at least some guidance from a professional. However, direct comparisons in randomised controlled trials are scarce and, to the best of our knowledge, the comparative (cost)-effectiveness of guided vs. unguided iSMI has not yet been studied. Hence, this study investigates the acceptability and (cost-) effectiveness of minimal guided and unguided iSMI in employees with heightened levels of perceived stress.

Methods

A three-armed randomised controlled trial (RCT) will be conducted to compare a minimal guided and unguided iSMI with a waiting list control condition (WLC). Both active conditions are based on the same iSMI, i.e. GET.ON Stress, and differ only with regard to the guidance format. Employees with heightened levels of perceived stress (PSS ≥ 22) will be randomised to one of three conditions. Primary outcome will be comparative changes in perceived stress (PSS). Secondary outcomes include changes in self-reported depression, work-engagement, presenteeism and absenteeism. Moreover, a cost-effectiveness analysis will be conducted from a societal perspective, including both direct medical costs and costs related to productivity losses. In addition, a cost-benefit analysis will be conducted from the employer’s perspective. Incremental net-benefit regression analyses will address the question if there are any baseline factors (i.e. subgroups of employees) associated with particularly favorable cost-effectiveness when the experimental intervention is offered. Assessments take place at baseline, 7 weeks post-treatment and 6 months after randomisation.

Discussion

Online-based (guided) self-help interventions could be an acceptable, effective and economically sustainable approach to offer evidence-based intervention alternatives to reduce the negative consequences associated with work-related stress. This study evaluates the (cost-) effectiveness of two versions of an iSMI, minimal guided and unguided iSMI. Thus, the present study will further enhance the evidence-base for iSMI and provide valuable information about the optimal balance between outcome and economic costs.

Trial registration

German Clinical Trial Registration (DRKS): DRKS00005687.

Long-term results of a web-based guided self-help intervention for employees with depressive symptoms: randomized controlled trial

Background

Depressive disorders are highly prevalent in the working population and are associated with excessive costs. The evidence for effective worker-directed interventions for employees with depressive symptoms is limited. Treating employees with depressive symptoms via the Internet before they report sick from work could be beneficial and cost saving.

Objective

In this study, we tested the effectiveness over the period of 1 year of a Web-based guided self-help intervention, called Happy@Work, for employees with depressive symptoms who were not on sick leave.

Methods

A two-arm randomized controlled trial comparing a worker-directed, Web-based, guided self-help intervention to care as usual (CAU) was carried out. We recruited employees from 6 companies via the company’s Intranet and by putting up posters. The inclusion criteria were elevated depressive symptoms as measured by a score ≥16 on the Center for Epidemiologic Studies Depression scale (CES-D) and not being on sick leave. The intervention contained 6 lessons and consisted of problem-solving treatment and cognitive therapy. Participants were asked to submit weekly assignments via the website after completion of a lesson and they received feedback from a coach via the website. Self-report questionnaires on depressive symptoms (CES-D; primary outcome), burnout (Maslach Burnout Inventory, MBI), work performance (Health and Work Performance Questionnaire, HPQ), duration of absenteeism, and anxiety (Hospital Anxiety and Depression Scale, HADS; secondary outcomes), were completed at baseline, posttreatment, and at 6-, and 12-month follow-up. Several subgroup and per-protocol analyses were performed.

Results

A total of 231 employees were randomized to either the intervention group (n=116) or to CAU (n=115). Completion of assessments varied between 54%-74%. Improvement in depressive symptoms between baseline and posttreatment was shown in all participants and these effects sustained over time. However, there were no differences between the 2 groups (adjusted regression coefficient=0.46, 95% CI –2.11 to 3.03, P=.72; Cohen’s d=0.05). Differences between groups were also not significant for the secondary outcomes. No subgroups were identified to show differences between the groups, nor did we find a between-group effect in the per-protocol analyses.

Conclusions

This study showed that a worker-directed, Web-based, guided self-help intervention was not more effective than CAU in reducing depressive symptoms among employees with depressive symptoms who were not on sick leave over the period of 1 year. An intervention for this specific target group might not be necessary because the recovery in the CAU group was comparable to the intervention group and sustained over a 12-month period.

Trial Registration

Nederlands Trial Register (NTR): NTR2993; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2993 (Archived by WebCite at http://www.webcitation.org/6PL9pFC0n).

Effects of an Internet-based cognitive behavioral therapy (iCBT) program in Manga format on improving subthreshold depressive symptoms among healthy workers: a randomized controlled trial

OBJECTIVE

The purpose of this study was to develop a new Internet-based computerized cognitive behavior therapy (iCBT) program in Manga format, the Japanese cartoon, for workers and to examine the effects of the iCBT program on improving subthreshold depression using a randomized controlled trial (RCT) design among workers employed in private companies in Japan.

METHOD

All workers in a company (n = 290) and all workers in three departments (n = 1,500) at the headquarters of another large company were recruited by an invitation e-mail. Participants who fulfilled the inclusion criteria were randomly allocated to intervention or control groups (N = 381 for each group). A six-week, six-lesson iCBT program using Manga (Japanese comic) story was developed. The program included several CBT skills: self-monitoring, cognitive restructuring, assertiveness, problem solving, and relaxation. The intervention group studied the iCBT program at a frequency of one lesson per week. Depression (Beck Depression Inventory II; BDI-II) was assessed as a primary outcome at baseline, and three- and six-month follow-ups for both intervention and control groups were performed.

RESULTS

The iCBT program showed a significant intervention effect on BDI-II (t = -1.99, p<0.05) with small effect sizes (Cohen's d: -0.16, 95% Confidence Interval: -0.32 to 0.00, at six-month follow-up).

CONCLUSIONS

The present study first demonstrated that a computerized cognitive behavior therapy delivered via the Internet was effective in improving depression in the general working population. It seems critical to improve program involvement of participants in order to enhance the effect size of an iCBT program.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000006210.

Short-term effects of a web-based guided self-help intervention for employees with depressive symptoms: randomized controlled trial

Background

Depressive disorders are highly prevalent in the working population and are associated with excessive costs. The evidence for effective worker-directed interventions for employees with depressive symptoms is limited. Treating employees with depressive symptoms before sick leave via the Internet could be beneficial and cost saving.

Objective

In this study, we developed and tested the effectiveness of a Web-based guided self-help course for employees with depressive symptoms. We report on the posttreatment effectiveness of the intervention.

Methods

This study is a two-arm randomized controlled trial comparing a Web-based guided self-help course to care as usual (CAU). We recruited employees from 6 different companies via the companies’ intranet and posters. The main inclusion criterion was elevated depressive symptoms as measured by a score of ≥16 on the Center for Epidemiological Studies Depression scale (CES-D). The intervention (Happy@Work) was based on problem-solving treatment and cognitive therapy and consisted of 6 weekly lessons. Participants were asked to submit their weekly assignment via the website after completion. They subsequently received feedback from a coach via the website. Self-report questionnaires on depressive symptoms (CES-D; primary outcome), anxiety measured by the Hospital Anxiety and Depression Scale (HADS), burnout measured by the Maslach Burnout Inventory (MBI), and work performance measured by the Health and Work Performance Questionnaire (HPQ; secondary outcomes) were completed at baseline and at posttreatment.

Results

A total of 231 employees were randomized to either the intervention group (n=116) or CAU (n=115).The posttreatment assessment was completed by 171 (74.0%) participants. Both the intervention and the CAU group showed significant improvements in the primary outcome of depressive symptoms, but no differences between the conditions was found (d=0.16, 95% CI –0.10 to 0.41, P=.29). Significant but small effects in favor of the intervention group were found for anxiety symptoms (d=0.16, 95% CI –0.09 to 0.42, P=.04) and exhaustion (d=0.17, 95% CI –0.09 to 0.43, P=.02).

Conclusions

This study showed that a Web-based guided self-help course for employees with depressive symptoms was not more effective in reducing depressive symptoms among employees than CAU. Large improvements in depressive symptoms in the CAU group were unforeseen and potential explanations are discussed.

Internet-based versus face-to-face cognitive-behavioral intervention for depression: a randomized controlled non-inferiority trial

BACKGROUND AND AIMS

In the past decade, a large body of research has demonstrated that internet-based interventions can have beneficial effects on depression. However, only a few clinical trials have compared internet-based depression therapy with an equivalent face-to-face treatment. The primary aim of this study was to compare treatment outcomes of an internet-based intervention with a face-to-face intervention for depression in a randomized non-inferiority trial.

METHOD

A total of 62 participants suffering from depression were randomly assigned to the therapist-supported internet-based intervention group (n=32) and to the face-to-face intervention (n=30). The 8 week interventions were based on cognitive-behavioral therapy principles. Patients in both groups received the same treatment modules in the same chronological order and time-frame. Primary outcome measure was the Beck Depression Inventory-II (BDI-II); secondary outcome variables were suicidal ideation, anxiety, hopelessness and automatic thoughts.

RESULTS

The intention-to-treat analysis yielded no significant between-group difference (online vs. face-to-face group) for any of the pre- to post-treatment measurements. At post-treatment both treatment conditions revealed significant symptom changes compared to before the intervention. Within group effect sizes for depression in the online group (d=1.27) and the face-to-face group (d=1.37) can be considered large. At 3-month follow-up, results in the online group remained stable. In contrast to this, participants in the face-to-face group showed significantly worsened depressive symptoms three months after termination of treatment (t=-2.05, df=19, p<.05).

LIMITATIONS

Due to the small sample size, it will be important to evaluate these outcomes in adequately-powered trials.

CONCLUSIONS

This study shows that an internet-based intervention for depression is equally beneficial to regular face-to-face therapy. However, more long term efficacy, indicated by continued symptom reduction three months after treatment, could be only be found for the online group.

Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults

BACKGROUND

Anxiety disorders are the most common mental health problems. They are chronic and unremitting. Effective treatments are available, but access to services is limited. Media-delivered behavioural and cognitive behavioural interventions (self-help) aim to deliver treatment with less input from professionals compared with traditional therapies.

OBJECTIVES

To assess the effects of media-delivered behavioural and cognitive behavioural therapies for anxiety disorders in adults.

SEARCH METHODS

Published and unpublished studies were considered without restriction by language or date. The Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR) was searched all years to 1 January 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Complementary searches were carried out on Ovid MEDLINE (1950 to 23 February 2013) and PsycINFO (1987 to February, Week 2, 2013), together with International trial registries (the trials portal of the World Health Organization (ICTRP) and ClinicalTrials.gov). Reference lists from previous meta-analyses and reports of randomised controlled trials were checked, and authors were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials of media-delivered behavioural or cognitive behavioural therapy in adults with anxiety disorders (other than post-traumatic stress disorder) compared with no intervention (including attention/relaxation controls) or compared with face-to-face therapy.

DATA COLLECTION AND ANALYSIS

Both review authors independently screened titles and abstracts. Study characteristics and outcomes were extracted in duplicate. Outcomes were combined using random-effects models, and tests for heterogeneity and for small study bias were conducted. We examined subgroup differences by type of disorder, type of intervention provided, type of media, and recruitment methods used.

MAIN RESULTS

One hundred and one studies with 8403 participants were included; 92 studies were included in the quantitative synthesis. These trials compared several types of media-delivered interventions (with varying levels of support) with no treatment and with face-to-face interventions. Inconsistency and risk of bias reduced our confidence in the overall results. For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants). The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice. Evidence suggested benefit for secondary outcome measures (depression, mental-health related disability, quality of life and dropout), but this evidence was of low to moderate quality. Evidence regarding harm was lacking.

AUTHORS' CONCLUSIONS

Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior. Economic analyses were beyond the scope of this review.Important heterogeneity was noted across trials. Recent interventions for specific problems that incorporate clinician support may be more effective than transdiagnostic interventions (i.e. interventions for multiple disorders) provided with no guidance, but these issues are confounded in the available trials.Although many small trials have been conducted, the generalisability of their findings is limited. Most interventions tested are not available to consumers. Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established. Large, pragmatic trials are needed to evaluate and to maximise the benefits of self-help interventions.

Efficacy and cost-effectiveness of a web-based and mobile stress-management intervention for employees: design of a randomized controlled trial

Background

Work-related stress is associated with a variety of mental and emotional problems and can lead to substantial economic costs due to lost productivity, absenteeism or the inability to work. There is a considerable amount of evidence on the effectiveness of traditional face-to-face stress-management interventions for employees; however, they are often costly, time-consuming, and characterized by a high access threshold. Web-based interventions may overcome some of these problems yet the evidence in this field is scarce. This paper describes the protocol for a study that will examine the efficacy and cost-effectiveness of a web-based guided stress-management training which is based on problem solving and emotion regulation and aimed at reducing stress in adult employees.

Methods

The study will target stressed employees aged 18 and older. A randomized controlled trial (RCT) design will be applied. Based on a power calculation of d=.35 (1-β of 80%, α = .05), 264 participants will be recruited and randomly assigned to either the intervention group or a six-month waitlist control group. Inclusion criteria include an elevated stress level (Cohen’s Perceived Stress Scale-10 ≥ 22) and current employment. Exclusion criteria include risk of suicide or previously diagnosed psychosis or dissociative symptoms. The primary outcome will be perceived stress, and secondary outcomes include depression and anxiety. Data will be collected at baseline and seven weeks and six months after randomization. An extended follow up at 12 months is planned for the intervention group. Moreover, a cost-effectiveness analysis will be conducted from a societal perspective and will include both direct and indirect health care costs. Data will be analyzed on an intention-to-treat basis and per protocol.

Discussion

The substantial negative consequences of work-related stress emphasize the necessity for effective stress-management trainings. If the proposed internet intervention proves to be (cost-) effective, a preventative, economical stress-management tool will be conceivable. The strengths and limitations of the present study are discussed.

Trial registration

German Register of Clinical Studies (DRKS): DRKS00004749

Feasibility of a personal health technology-based psychological intervention for men with stress and mood problems: randomized controlled pilot trial

BACKGROUND

Work-related stress is a significant problem for both people and organizations. It may lead to mental illnesses such as anxiety and depression, resulting in increased work absences and disabilities. Scalable interventions to prevent and manage harmful stress can be delivered with the help of technology tools to support self-observations and skills training.

OBJECTIVE

The aim of this study was to assess the feasibility of the P4Well intervention in treatment of stress-related psychological problems. P4Well is a novel intervention which combines modern psychotherapy (the cognitive behavioral therapy and the acceptance and commitment therapy) with personal health technologies to deliver the intervention via multiple channels, includinggroup meetings, Internet/Web portal, mobile phone applications, and personal monitoring devices.

METHODS

This pilot study design was a small-scale randomized controlled trial that compared the P4Well intervention with a waiting list control group. In addition to personal health technologies for self-assessment, the intervention consisted of 3 psychologist-assisted group meetings. Self-assessed psychological measures through questionnaires were collected offline pre- and post-intervention, and 6 months after the intervention for the intervention group. Acceptance and usage of technology tools were measured with user experience questionnaires and usage logs.

RESULTS

A total of 24 subjects were randomized: 11 participants were followed up in the intervention group (1 was lost to follow-up) and 12 participants did not receive any intervention (control group). Depressive and psychological symptoms decreased and self-rated health and working ability increased. All participants reported they had benefited from the intervention. All technology tools had active users and 10/11 participants used at least 1 tool actively. Physiological measurements with personal feedback were considered the most useful intervention component.

CONCLUSIONS

Our results confirm the feasibility of the intervention and suggest that it had positive effects on psychological symptoms, self-rated health, and self-rated working ability. The intervention seemed to have a positive impact on certain aspects of burnout and job strain, such as cynicism and over-commitment. Future studies need to investigate the effectiveness, benefits, and possible problems of psychological interventions which incorporate new technologies.

TRIAL REGISTRATION

The Finnish Funding Agency for Technology and Innovation (TEKES), Project number 40011/08.

The therapeutic relationship in e-therapy for mental health: a systematic review

Background

E-therapy is defined as a licensed mental health care professional providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these. The use of e-therapy has been rapidly expanding in the last two decades, with growing evidence suggesting that the provision of mental health services over the Internet is both clinically efficacious and cost effective. Yet there are still unanswered concerns about e-therapy, including whether it is possible to develop a successful therapeutic relationship over the Internet in the absence of nonverbal cues.

Objective

Our objective in this study was to systematically review the therapeutic relationship in e-therapy.

Methods

We searched PubMed, PsycINFO, and CINAHL through August 2011. Information on study methods and results was abstracted independently by the authors using a standardized form.

Results

From the 840 reviewed studies, only 11 (1.3%) investigated the therapeutic relationship. The majority of the reviewed studies were focused on the therapeutic alliance—a central element of the therapeutic relationship. Although the results do not allow firm conclusions, they indicate that e-therapy seems to be at least equivalent to face-to-face therapy in terms of therapeutic alliance, and that there is a relationship between the therapeutic alliance and e-therapy outcome.

Conclusions

Overall, the current literature on the role of therapeutic relationship in e-therapy is scant, and much more research is needed to understand the therapeutic relationship in online environments.