Internet-based CBT for depression with and without telephone tracking in a national helpline: randomised controlled trial

Skill Enactment Among University Students Using a Brief Video-Based Mental Health Intervention: Mixed Methods Study Within a Randomized Controlled Trial

BACKGROUND

Mental health problems are common among university students, yet many students do not seek professional help. Digital mental health interventions can increase students' access to support and have been shown to be effective in preventing and treating mental health problems. However, little is known about the extent to which students implement therapeutic skills from these programs in everyday life (ie, skill enactment) or about the impact of skill enactment on outcomes.

OBJECTIVE

This study aims to assess the effects of a low-intensity video-based intervention, Uni Virtual Clinic Lite (UVC-Lite), in improving skill enactment relative to an attention-control program (primary aim) and examine whether skill enactment influences symptoms of depression and anxiety (secondary aim). The study also qualitatively explored participants' experiences of, and motivations for, engaging with the therapeutic techniques.

METHODS

We analyzed data from a randomized controlled trial testing the effectiveness of UVC-Lite for symptoms of depression and anxiety among university students with mild to moderate levels of psychological distress. Participants were recruited from universities across Australia and randomly assigned to 6 weeks of self-guided use of UVC-Lite (243/487, 49.9%) or an attention-control program (244/487, 50.1%). Quantitative data on skill enactment, depression, and anxiety were collected through baseline, postintervention, and 3- and 6-month follow-up surveys. Qualitative data were obtained from 29 intervention-group participants through open-ended questions during postintervention surveys (n=17, 59%) and semistructured interviews (n=12, 41%) after the intervention period concluded.

RESULTS

Mixed model repeated measures ANOVA demonstrated that the intervention did not significantly improve skill enactment (F3,215.36=0.50; P=.68). Skill enactment was also not found to influence change in symptoms of depression (F3,241.10=1.69; P=.17) or anxiety (F3,233.71=1.11; P=.35). However, higher levels of skill enactment were associated with lower symptom levels among both intervention and control group participants across time points (depression: F1,541.87=134.61; P<.001; anxiety: F1,535.11=73.08; P<.001). Inductive content analysis confirmed low levels of skill enactment among intervention group participants. Participants were motivated to use techniques and skills that were perceived to be personally relevant, easily integrated into daily life, and that were novel or had worked for them in the past.

CONCLUSIONS

The intervention did not improve skill enactment or mental health among students with mild to moderate psychological distress. Low adherence impacted our ability to draw robust conclusions regarding the intervention's impact on outcomes. Factors influencing skill enactment differed across individuals, suggesting that it may be necessary to tailor therapeutic skills and engagement strategies to the individual user. Theoretically informed research involving collaboration with end users is needed to understand the processes underlying skill enactment in digital mental health interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000375853; https://tinyurl.com/7b9ar54r.

Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis

Importance

While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary.

Objective

To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness.

Data Sources

A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials.

Study Selection

Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted.

Main Outcomes and Measures

Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs.

Results

The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46).

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Improving mental health literacy using web- or app-based interventions: A scoping review

Background

Given the rapid advancement in technology, the Internet has grown to play a significant role in the field of healthcare. Individuals can now access a profusion of easily available materials for self-management of their health. The purpose of this review is to describe Web/App-based interventions that are primarily or secondarily designed to improve mental health literacy (MHL) and to investigate the effectiveness of online interventions for improving mental health.

Materials and Method

A scoping review was conducted by searching five databases: PsycINFO, EMBASE, PubMed, CINAHL, and Web of Science. The search was limited to peer-reviewed journals published in English between 2000 and 2022. Studies focusing on enhancements of MHL or its constituent components were included.

Results

Twenty-four studies met the inclusion criteria. The interventions primarily targeted patients or individuals exhibiting symptoms of mental disorders, with a higher representation of female participants. All the interventions yielded positive outcomes. The included studies were categorized according to three themes: knowledge, attitude, and self-care skills. Although numerous studies have focused on knowledge improvement, research on interventions targeting self-care skills is scarce. Furthermore, existing literature on knowledge enhancement is limited in terms of the coverage of risk factors.

Conclusion

This review indicates gaps in web/app interventions including limited evidence on risk factors, inconsistent help-seeking awareness, and inadequate self-care skills training. Further research is critically needed to address these deficiencies and promote comprehensive MHL.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

A randomised controlled trial of clinician supported vs self-help delivery of online cognitive behaviour therapy for Bulimia Nervosa

High dropout rates and poor adherence associated with digital interventions have prompted research into modifications of these treatments to improve engagement and completion rates. This trial aimed to investigate the added benefit of clinician support when paired alongside a ten-session, online cognitive behaviour therapy (CBT) self-help intervention for bulimia nervosa (BN). As part of a three-arm, phase II randomised controlled trial, 114 participants (16 years or over) with full or subthreshold BN were randomly assigned to complete the intervention in a self-help mode (with administrative researcher contact; n = 38), with adjunct clinician support (weekly 30-minute videoconferencing sessions; n = 37), or a no-treatment waitlist control (WLC; n = 39). Baseline to post-treatment (12-weeks) decreases in objective binge episode frequency were significantly greater for clinician-supported participants as compared to WLC, but not for self-help when compared to WLC. However, due to continued improvements for self-help across follow-up (24-weeks), both arms outperformed WLC when analysed as an overall rate of change across three timepoints. Clinician-supported participants outperformed self-help in regards to laxative use and dietary restraint. Our results demonstrate that good clinical outcomes can be achieved with a relatively brief online CBT-based program even in the absence of structured clinical support, indicating a possible overreliance upon clinician support as a primary adherence-facilitating mechanism.

Cultural Responsivity in Technology-Enabled Services: Integrating Culture Into Technology and Service Components

Technology-enabled services (TESs) are clinical interventions that combine technological and human components to provide health services. TESs for mental health are efficacious in the treatment of anxiety and depression and are currently being offered as frontline treatments around the world. It is hoped that these interventions will be able to reach diverse populations across a range of identities and ultimately decrease disparities in mental health treatment. However, this hope is largely unrealized. TESs include both technology and human service components, and we argue that cultural responsivity must be considered in each of these components to help address existing treatment disparities. To date, there is limited guidance on how to consider cultural responsivity within these interventions, including specific targets for the development, tailoring, or design of the technologies and services within TESs. In response, we propose a framework that provides specific recommendations for targets based on existing models, both at the technological component level (informed by the Behavioral Intervention Technology Model) and the human support level (informed by the Efficiency Model of Support). We hope that integrating culturally responsive considerations into these existing models will facilitate increased attention to cultural responsivity within TESs to ensure they are ethical and responsive for everyone.

Implementing Digital Cognitive-Behavioral Therapy for Major Depressive Disorder in Routine Psychiatric Appointments: A Pilot Project in a Rural Population

Psychotherapy is well-established as an effective treatment for major depressive disorder (MDD). However, many individuals with MDD in rural areas of the United States do not have access to psychotherapy. Self-management (SM) strategies are now the standard of care for chronic medical conditions and may be a viable alternative for individuals without access to psychotherapy. The current article describes the implementation of a 13-week pilot project to integrate digital cognitive-behavioral therapy (dCBT) SM programs into routine psychiatric advanced practice nurse (APN) telehealth appointments in the rural United States. Eight participants completed the project. The project did not meet the benchmark of 20 participants to improve access to treatment; however, one half (n = 4) of participants reported clinically significant improvement in MDD symptoms over 6 weeks. For clients without access to psychotherapy, dCBT SM programs can be effective in improving individual client outcomes when implemented by APNs in routine telehealth appointments. [Journal of Psychosocial Nursing and Mental Health Services, 61(10), 44-51.].

Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults With Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Depression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention.

OBJECTIVE

This systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life.

METHODS

The Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October).

RESULTS

The search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] -0.43, 95% CI -0.67 to -0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001).

CONCLUSIONS

This systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements.

The impact of technology systems and level of support in digital mental health interventions: a secondary meta-analysis

BACKGROUND

The majority of people with a chronic disease (e.g., diabetes, hypertension, COPD) have more than one concurrent condition and are also at higher risk for developing comorbidities in mental health, including anxiety and depression. There is an urgent need for more relevant and accurate data on digital interventions in this area to prepare for an increase demand for mental health services. The aim of this study was to conduct a meta-analysis of the digital mental health interventions for people with comorbid physical and mental chronic diseases to compare the effect of technology systems and level of support.

METHODS

This secondary meta-analysis follows a rapid review of systematic reviews, a virtual workshop with knowledge users to identify research questions and a modified Delphi study to guide research methods: What types of digital health interventions (according to a recognized categorization) are the most effective for the management of concomitant mental health and chronic disease conditions in adults? We conducted a secondary analysis of the primary studies identified in the rapid review. Two reviewers independently screened the titles and abstracts and applied inclusion criteria: RCT design using a digital mental health intervention in a population of adults with another chronic condition, published after 2010 in French or English, and including an outcome measurement of anxiety or depression.

RESULTS

Seven hundred eight primary studies were extracted from the systematic reviews and 84 primary studies met the inclusion criteria Digital mental health interventions were significantly more effective than in-person care for both anxiety and depression outcomes. Online messaging was the most effective technology to improve anxiety and depression scores; however, all technology types were effective. Interventions partially supported by healthcare professionals were more effective than self-administered.

CONCLUSIONS

While our meta-analysis identifies digital intervention's characteristics are associated with better effectiveness, all technologies and levels of support could be used considering implementation context and population.

TRIAL REGISTRATION

The protocol for this review is registered in the National Collaborating Centre for Methods and Tools (NCCMT) COVID-19 Rapid Evidence Service (ID 75).

Efficacy of computer- and/or internet-based cognitive-behavioral guided self-management for depression in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Depression is a worldwide disease. CBT-based self-help treatment allows patients with mild to moderate depression symptoms to improve their depression or to bridge the waiting- or pandemic period until they receive further clinical treatment.

OBJECTIVE

This systematic review and meta-analysis aims to explore the efficacy, acceptability and improvement in quality of life of computer-delivered and/or internet-based CBT self-help interventions with minimal guidance (up to 10 min) for depression. The second aim was to compare the effectiveness of reducing depression symptoms at post-treatment of treatment by the type of minimal guidance: (1) e-mail, (2) telephone calls, (3) e-mail and telephone together, or (4) face-to-face.

METHODS

The Cochrane depression, anxiety, and neurosis review group's specialized register electronic searches, grey literature, reference lists and correspondence were used to search for published and unpublished RCTs that reported efficacy of computer- and/or internet-based CBT self-help treatments for depression with minimal guidance up to 10 min per week. Methodological quality of included studies was evaluated with Cochrane Collaboration tools for assessing risk of bias. The meta-analysis was accomplished using the RevMen software.

RESULTS

In total, 2809 study abstracts were checked for eligibility. Out of these, 19 studies (21 samples) with a total of 3226 participants were included. The results showed that concerning efficacy, the treatment group is superior to the control group with a medium to large effect size of 0.65. Also, treatment groups with combined guidance by e-mail and telephone calls together had greater effects (SMD -0.76) than groups with other types of minimal guidance (guided by e-mail SMD -0.63; guided face to-face SMD - 0.66; guided by telephone calls SMD -0.49). Findings showed also, that iCBT with minimal guidance had small but statistically significant effect size of 0.28 in improving quality of life. Moreover, there were higher drop-out rates in the treatment condition (RR 1.36) than in the control groups.

CONCLUSIONS

The results of this meta-analysis support the efficacy of computer- and/or internet-based CBT self-help programs with minimal weekly guidance up to only 10 min for improving depression symptoms at post-treatment for adults. In addition, the results are pointing towards two practical implications. Firstly, depressed persons can use self-help treatment with minimal guidance at home to improve their symptoms or to bridge the waiting time - or pandemic period - before they receive professional face-to-face treatment. Secondly, it can help clinicians to make the decision about using CBT-based self-help treatments for patients that do not need urgent professional treatment, or to combine it with face-to-face therapy.

The effect of cognitive behavior therapy on anxiety and depression during COVID-19 pandemic: a systematic review and meta-analysis

BACKGROUND

The global spread of coronavirus has caused many physical and mental health problems throughout the world. Depression and anxiety are among the issues that people are experiencing abundantly, along with other mental health disorders, during this period. Cognitive behavior therapy (CBT) is one of the approaches that is effective on improving most of the psychological issues including depression and anxiety. The objective of this systematic review and meta-analysis was to assess the effects of CBT on depression and anxiety during COVID-19 pandemic period.

METHODS

English databases such as Cochrane, PubMed, Google Scholar, Web of Science and Persian databases such as SID, MagIran and IranDoc were searched with a time limit of 2019 to 2022. Two researchers independently evaluated the quality of the entered studies based on Cochrane handbook. Subgroup analysis was conducted separately on the basis of being infected with coronavirus, not being infected with coronavirus, and having a history of depression or anxiety before the intervention and internet-based CBT for depression and anxiety. Meta-analysis results were reported using standardized mean difference (SMD) and 95% confidence interval (95% CI). Heterogeneity of studies was analyzed by means of I2 index; and in the case of heterogeneity presence, random effects model was used instead of fixed effects model. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used for evaluating the quality of evidence.

RESULTS

Totally, 2015 articles were analyzed of which 11 articles entered meta-analysis. The overall results of meta-analysis showed that mean score of anxiety in the group receiving CBT was significantly lower than the control group (SMD: - 0.95, 95% CI - 1.29 to - 0.62; P < 0.00001, I2 = 94%). In addition, mean score of depression in the intervention group was significantly lower than the control group (SMD: - 0.58; 95% CI - 1.00 to - 0.16, P < 0.00001, I2 = 94%). In addition, the results of subgroup meta-analysis showed that internet-based CBT was effective in reducing of depression (SMD - 0.35; 95% CI - 0.50 to - 0.20; P < 0.00001; I2 = 0%) and anxiety (SMD - 0.90; 95%CI - 1.47 to - 0.33; P = 0.002; I2 = 94%). The evidence about the effectiveness of CBT on depression and anxiety compared with control group on the basis of GRADE approach had low quality.

CONCLUSIONS

Meta-analysis results showed that CBT reduced the mean scores of anxiety and depression significantly during COVID-19 pandemic period. Due to the low quality of evidence, conducting more randomized controlled trials with rigorous design is suggested. Prospero registration This systematic review has been registered in Prospero (ID: CRD42021277213).

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for 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.

Characteristics of Mobile Health Platforms for Depression and Anxiety: Content Analysis Through a Systematic Review of the Literature and Systematic Search of Two App Stores

Background

Mobile health (mHealth) platforms show promise in the management of mental health conditions such as anxiety and depression. This has resulted in an abundance of mHealth platforms available for research or commercial use.

Objective

The objective of this review is to characterize the current state of mHealth platforms designed for anxiety or depression that are available for research, commercial use, or both.

Methods

A systematic review was conducted using a two-pronged approach: searching relevant literature with prespecified search terms to identify platforms in published research and simultaneously searching 2 major app stores—Google Play Store and Apple App Store—to identify commercially available platforms. Key characteristics of the mHealth platforms were synthesized, such as platform name, targeted condition, targeted group, purpose, technology type, intervention type, commercial availability, and regulatory information.

Results

The literature and app store searches yielded 169 and 179 mHealth platforms, respectively. Most platforms developed for research purposes were designed for depression (116/169, 68.6%), whereas the app store search reported a higher number of platforms developed for anxiety (Android: 58/179, 32.4%; iOS: 27/179, 15.1%). The most common purpose of platforms in both searches was treatment (literature search: 122/169, 72.2%; app store search: 129/179, 72.1%). With regard to the types of intervention, cognitive behavioral therapy and referral to care or counseling emerged as the most popular options offered by the platforms identified in the literature and app store searches, respectively. Most platforms from both searches did not have a specific target age group. In addition, most platforms found in app stores lacked clinical and real-world evidence, and a small number of platforms found in the published research were available commercially.

Conclusions

A considerable number of mHealth platforms designed for anxiety or depression are available for research, commercial use, or both. The characteristics of these mHealth platforms greatly vary. Future efforts should focus on assessing the quality—utility, safety, and effectiveness—of the existing platforms and providing developers, from both commercial and research sectors, a reporting guideline for their platform description and a regulatory framework to facilitate the development, validation, and deployment of effective mHealth platforms.

Clinical wisdom in the age of computer apps: a systematic review of four functions that may complement clinical treatment

Mental health clinicians perform complex tasks with patients that potentially could be improved by the massive computing power available through mobile apps. This study aimed to analyse commercially available mobile and computer applications (apps) focused on treating psychiatric disorders. Apps were analysed by two independent raters for whether they took advantage of computer power to process data in a fashion that augments four main elements of clinical treatment including (1) assessment/diagnosis, (2) treatment planning, (3) treatment fidelity monitoring, and (4) outcome tracking. The evidence base for each of these apps was also explored via PsychINFO, Research Gate and Google Scholar. Searches of the Google Play Store, the Apple App Store, and the One Mind PsyberGuide found 722 apps labelled for mental health use, of which 163 apps were judged relevant to clinical work with patients with psychiatric disorders. Fifty-nine of these were determined to contain a computer-driven function for at least one of the four main elements of clinical treatment. The most common element was assessment/diagnosis (55/59 apps), followed by outcome tracking (34/59 apps). Six apps updated treatment plans using user input. Only one app tracked treatment fidelity. None of the apps contained computer-driven functions for all four elements. Twelve apps were supported in randomized clinical trials to show greater efficacy compared with either wait-list or other active treatments. Results showed that these four clinical elements can be meaningfully augmented, but the full potential of computer processing appears unreached in mental health-related apps.

Key learning aims

(1)

Technology-supported strategies for promoting user engagement with digital mental health interventions: A systematic review

Background

Although digital mental health interventions (DMHIs) offer a potential solution for increasing access to mental health treatment, their integration into real-world settings has been slow. A key reason for this is poor user engagement. A growing number of studies evaluating strategies for promoting engagement with DMHIs means that a review of the literature is now warranted. This systematic review is the first to synthesise evidence on technology-supported strategies for promoting engagement with DMHIs.

Methods

MEDLINE, EmbASE, PsycINFO and PubMed databases were searched from 1 January 1995 to 1 October 2021. Experimental or quasi-experimental studies examining the effect of technology-supported engagement strategies deployed alongside DMHIs were included, as were secondary analyses of such studies. Title and abstract screening, full-text coding and quality assessment were performed independently by two authors. Narrative synthesis was used to summarise findings from the included studies.

Results

24 studies (10,266 participants) were included. Engagement strategies ranged from reminders, coaching, personalised information and peer support. Most strategies were disseminated once a week, usually via email or telephone. There was some empirical support for the efficacy of technology-based strategies towards promoting engagement. However, findings were mixed regardless of strategy type or study aim.

Conclusions

Technology-supported strategies appear to increase engagement with DMHIs; however, their efficacy varies widely by strategy type. Future research should involve end-users in the development and evaluation of these strategies to develop a more cohesive set of strategies that are acceptable and effective for target audiences, and explore the mechanism(s) through which such strategies promote engagement.

Impact of guidance on intervention adherence in computerised interventions for mental health problems: a meta-analysis

Web-based interventions are increasingly used for the prevention, treatment and aftercare of mental disorders. A crucial factor to the efficacy of such online programmes is adherence to the intervention content and procedure. It has been frequently suggested that adherence in web-based interventions is low and little is known about which factors influence adherence. To increase intervention uptake and completion, studies increasingly include interventions with some form of guidance. Guided interventions have been shown to have higher efficacy, however, evidence for the impact on adherence is limited and mixed. This meta-analysis explored the impact of human guidance on intervention completion in web-based mental health interventions. A total of 22 studies were included with interventions primarily targeting symptoms of depression and anxiety disorders. Results showed that guidance significantly increases the average amount of intervention completion [g = 0.29, 95% confidence interval (CI) 0.18-0.40] and the proportion of intervention completers [log odds ratio (OR) = 0.50, 95% CI 0.34-0.66] with small effects. On average, full completion rates were 12% higher in guided intervention groups. This meta-analysis demonstrated that guidance in web-based mental health interventions does increase adherence, but more research is required to better understand the specific mechanisms between guidance, adherence and outcomes.

The effects of non-clinician guidance on effectiveness and process outcomes of digital mental health interventions: A systematic review and meta-analysis (Preprint)

Background

Digital mental health interventions are increasingly prevalent in the current context of rapidly evolving technology, and research indicates that they yield effectiveness outcomes comparable to in-person treatment. Integrating professionals (ie, psychologists and physicians) into digital mental health interventions has become common, and the inclusion of guidance within programs can increase adherence to interventions. However, employing professionals to enhance mental health programs may undermine the scalability of digital interventions. Therefore, delegating guidance tasks to paraprofessionals (peer supporters, technicians, lay counsellors, or other nonclinicians) can help reduce costs and increase accessibility.

Objective

This systematic review and meta-analysis evaluates the effectiveness, adherence, and other process outcomes of nonclinician-guided digital mental health interventions.

Methods

Four databases (MEDLINE, Embase, CINAHL, and PsycINFO) were searched for randomized controlled trials published between 2010 and 2020 examining digital mental health interventions. Three journals that focus on digital intervention were hand searched; gray literature was searched using ProQuest and the Cochrane Central Register of Control Trials (CENTRAL). Two researchers independently assessed risk of bias using the Cochrane risk-of-bias tool version 2. Data were collected on effectiveness, adherence, and other process outcomes, and meta-analyses were conducted for effectiveness and adherence outcomes. Nonclinician-guided interventions were compared with treatment as usual, clinician-guided interventions, and unguided interventions.

Results

Thirteen studies qualified for inclusion. Nonclinician-guided interventions yielded higher posttreatment effectiveness outcomes when compared to conditions involving control programs (eg, online psychoeducation and monitored attention control) or wait-list controls (k=7, Hedges g=–0.73; 95% CI –1.08 to –0.38). There were also significant differences between nonclinician-guided interventions and unguided interventions (k=6, Hedges g=–0.17; 95% CI –0.23 to –0.11). In addition, nonclinician-guided interventions did not differ in effectiveness from clinician-guided interventions (k=3, Hedges g=0.08; 95% CI –0.01 to 0.17). These results suggest that guided digital mental health interventions are helpful to improve mental health outcomes regardless of the qualifications of the individual performing the intervention, and that the presence of a nonclinician guide improves effectiveness outcomes compared to having no guide. Nonclinician-guided interventions did not yield significantly different adherence outcomes when compared with unguided interventions (k=3, odds ratio 1.58; 95% CI 0.51 to 4.92), although a general trend of improved adherence was observed within nonclinician-guided interventions.

Conclusions

Integrating paraprofessionals and nonclinicians appears to improve the outcomes of digital mental health interventions, and may also enhance adherence outcomes (though this trend was nonsignificant). Further research should focus on the specific types of tasks these paraprofessionals can successfully provide (ie, psychosocial support, therapeutic alliance, and technical augmentation) and their associated outcomes.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020191226; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=191226

Optimizing Coaching During Web-Based Relationship Education for Low-Income Couples: Protocol for Precision Medicine Research

Background

In-person relationship education classes funded by the federal government tend to experience relatively high attrition rates and have only a limited effect on relationships. In contrast, low-income couples tend to report meaningful gains from web-based relationship education when provided with individualized coach contact. However, little is known about the method and intensity of practitioner contact that a couple requires to complete the web-based program and receive the intended benefit.

Objective

The aim of this study is to use within-group models to create an algorithm to assign future couples to different programs and levels of coach contact, identify the most powerful predictors of treatment adherence and gains in relationship satisfaction within 3 different levels of coaching, and examine the most powerful predictors of treatment adherence and gains in relationship satisfaction among the 3 levels of coach contact.

Methods

To accomplish these goals, this project intends to use data from a web-based Sequential Multiple Assignment Randomized Trial of the OurRelationship and web-based Prevention and Relationship Enhancement programs, in which the method and type of coach contact were randomly varied across 1248 couples (2496 individuals), with the hope of advancing theory in this area and generating accurate predictions. This study was funded by the US Department of Health and Human Services, Administration for Children and Families (grant number 90PD0309).

Results

Data collection from the Sequential Multiple Assignment Randomized Trial of the OurRelationship and web-based Prevention and Relationship Enhancement Program was completed in October of 2020.

Conclusions

Some of the direct benefits of this study include benefits to social services program administrators, tailoring of more effective relationship education, and effective delivery of evidence- and web-based relationship health interventions.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33047

Remote delivery of cognitive behavioral therapy to patients with functional neurological disorders: Promise and challenges

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CBT is a promising treatment for patients with FND.

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Remote delivery of CBT can potentially increase access to care for patients with FND.

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Remote CBT can be integrated into clinical practice using a stepwise approach.

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Remote CBT can be integrated into practice using patient predictive factors.

Functional neurological disorders (FND) are an important source of healthcare utilization and morbidity. While there are no formal guidelines for treating these disorders, cognitive behavioral therapy (CBT) is emerging as a safe and effective treatment. Currently, there is a global shortage of CBT providers, with only a small subset trained in and comfortable with treating patients with FND. We highlight four types of remote CBT delivery to patients with FND to alleviate the access obstacle: workbooks, internet-guided CBT, app-based CBT, and teletherapy. CBT workbooks and teletherapy have been studied in FND, with preliminary studies suggesting efficacy; internet-guided CBT and app-based CBT have not but have been effectively used in patients with psychiatric disorders, particularly depression, anxiety, and post-traumatic disorders. As these disorders are often comorbid and share overlapping neurobiology with FND, internet-guided CBT and app-based CBT represent promising delivery options of CBT for FND. Although remotely-delivered CBT is unlikely to replace in-person CBT and there are technical and logistical challenges to overcome prior to widespread deployment, it holds promise as an adjunct treatment when in-person CBT is inaccessible. We propose a rational approach to future allocation of remote CBT treatment options and highlight important research gaps to bridge beforehand.

Delivering an Online Cognitive Behavioral Therapy Program to Address Mental Health Challenges Faced by Correctional Workers and Other Public Safety Personnel: Protocol for a Mixed Methods Study

BACKGROUND

Public safety personnel have regular and often intense exposure to potentially traumatic events at work, especially workplace violence in the case of correctional workers. Subsequently, correctional workers are at higher risk of developing mental health problems such as posttraumatic stress disorder. Public safety personnel are up to 4 times more likely to experience suicidal ideation, suicidal attempts, and death by suicide compared to the general population. Despite this high prevalence, help-seeking behaviors from public safety personnel are low due to stigma and irregular work hours limiting access to care. Innovative treatments are needed to address these challenges.

OBJECTIVE

This study will investigate the efficacy of an electronically delivered cognitive behavioral therapy (e-CBT) program tailored to correctional workers' mental health problems.

METHODS

This study is composed of 4 phases. In phase 1, we will interview correctional workers individually and in focus groups to identify personal, social, and cultural factors affecting their mental health and barriers to care. Phase 2 will use the information gathered from the interviews to develop gender- and diagnosis-specific e-CBT modules. These will be presented to a new group of participants who will provide further feedback on their usability and accessibility. In phase 3, we will randomly assign participants to either an e-CBT or treatment as usual arm. The program will be evaluated with validated symptomatology questionnaires and interviews. Phase 4 will use this additional information to fine-tune the e-CBT modules for a larger-scale randomized controlled trial design comparing the e-CBT program to in-person CBT. All e-CBT modules will be delivered through a secure online platform.

RESULTS

The study received ethics approval in December 2020, and participant recruitment began in March 2021. Participant recruitment has been conducted through targeted advertisements and physician referrals. To date, there have been 15 participants recruited for Phase 1, and it is expected to conclude in July 2021, with phase 2 beginning in September 2021. Complete data collection and analysis from all phases are expected to conclude by July 2023. Linear and binomial regression (for continuous and categorical outcomes, respectively) will be conducted along with interpretive qualitative methods.

CONCLUSIONS

If proven efficacious and feasible, this e-CBT program can provide a high-quality and clinically validated resource to address the mental health problems of correctional workers. Additionally, findings can contribute to the development of innovative treatments for other public safety professions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04666974; https://www.clinicaltrials.gov/ct2/show/NCT04666974.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30845.

Perception and barriers to the use of cognitive-behavioral therapy in the treatment of depression in primary healthcare centers and family medicine clinics in Saudi Arabia

BACKGROUND

General practitioners (GPs) and family medicine physicians (FMPs) have a vital role to play in co-ordinating the care for mental disorders. The objective of this study was to determine the perception of GPs and FMPs on the use of cognitive-behavioral therapy (CBT) for depression in Saudi Arabia, and the barriers against the implementation of CBT in such settings.

MATERIALS AND METHODS

All physicians working in Primary Healthcare Centers and Family Medicine Clinics in Saudi Arabia were targeted and invited to participate in this cross-sectional study. A self-administered online questionnaire was sent via E-mail through the Saudi Commission for Health Specialties and the Saudi Society of Family and Community Medicine. Data was collected using an existing validated questionnaire and was modified to fit the objectives of current study.

RESULTS

A total of 469 FMPs and GPs completed the survey; the mean age of respondents was 38 years. More than half of the FMPs' and GPs' (53%) showed a positive perception of the use of CBT in primary healthcare settings. Most participants (91.9%) were willing to use CBT if they had adequate education and training. More than half of the participants (59.5%) thought it was time-consuming, while 39% thought that CBT training was a very time-intensive process.

CONCLUSION

We conclude that more than half of the physicians clearly had a good perception of the effectiveness of CBT administration in primary healthcare settings. Younger physicians were more perceptive. The most agreed-on barrier to CBT implementation was the lack of training and education.

Exploring the Role of Persuasive Design in Unguided Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Adults: Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND

Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT.

OBJECTIVE

This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety.

METHODS

We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design.

RESULTS

Of the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=0.27; B=0.04; P=.02) but not anxiety (R2 change=0.05; B=0.03; P=.17).

CONCLUSIONS

These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT.

Internet-Based Cognitive Behavioral Therapy for Depression: A Systematic Review and Individual Patient Data Network Meta-analysis

Importance

Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them.

Objective

To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information.

Data Sources

We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019.

Study Selection

Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization.

Data Extraction and Synthesis

We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression.

Main Outcomes and Measures

Patient Health Questionnaire-9 (PHQ-9) scores.

Results

Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9.

Conclusions and Relevance

In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.

Efficacy of Guided Versus Self-Induced Learning of Web-Based Self-Compassionate Journaling by College Students

We conducted 3 studies examining the efficacy of web-based self-compassionate journaling (SCJ). The goal was to compare the effects of guided and self-administered journaling on self-reported follow-up self-compassion scores and participant perceptions of the induction. In Study 1 participants were randomly assigned to an online SCJ exercise, online narrative journaling control group, or attention control (AC) group, with groups completing tasks for 4 weeks. In Study 2 participants self-selected into either online or in-lab conditions to complete a single-time SCJ exercise. Study 3 was a replication of Study 2, with participants being randomly assigned to conditions. There were no differences in self-compassion between groups in Study 1. However, there was a small but significant overall increase in self-compassion among participants from baseline to follow-up. There were self-compassion differences between online and in-lab groups in Study 2 (with a small effect size). However, these differences were not maintained when the covariate of baseline trait self-compassion was removed from analyses. Study 3 failed to replicate significant findings from Study 2 in all but one variable: whether participants completing the induction alone found the task more difficult to complete. In general, SCJ may not be an adequate way to increase self-compassion regardless of whether it is learned online or in a laboratory setting. Furthermore, those who learn SCJ alone online report difficulty in completing the induction.

Demanding and effective: participants' experiences of internet-delivered prolonged exposure provided within two months after exposure to trauma

Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants' experiences in receiving this type of intervention remotely. Objective: Investigate participants' experiences of receiving CIPE early after trauma. Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim. Results: One overarching theme labelled as 'demanding and effective' was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure. Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.

Adaptive Elements in Internet-Delivered Psychological Treatment Systems: Systematic Review

BACKGROUND

Internet-delivered psychological treatments (IDPTs) are built on evidence-based psychological treatment models, such as cognitive behavioral therapy, and are adjusted for internet use. The use of internet technologies has the potential to increase access to evidence-based mental health services for a larger proportion of the population with the use of fewer resources. However, despite extensive evidence that internet interventions can be effective in the treatment of mental health disorders, user adherence to such internet intervention is suboptimal.

OBJECTIVE

This review aimed to (1) inspect and identify the adaptive elements of IDPT for mental health disorders, (2) examine how system adaptation influences the efficacy of IDPT on mental health treatments, (3) identify the information architecture, adaptive dimensions, and strategies for implementing these interventions for mental illness, and (4) use the findings to create a conceptual framework that provides better user adherence and adaptiveness in IDPT for mental health issues.

METHODS

The review followed the guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The research databases Medline (PubMed), ACM Digital Library, PsycINFO, CINAHL, and Cochrane were searched for studies dating from January 2000 to January 2020. Based on predetermined selection criteria, data from eligible studies were analyzed.

RESULTS

A total of 3341 studies were initially identified based on the inclusion criteria. Following a review of the title, abstract, and full text, 31 studies that fulfilled the inclusion criteria were selected, most of which described attempts to tailor interventions for mental health disorders. The most common adaptive elements were feedback messages to patients from therapists and intervention content. However, how these elements contribute to the efficacy of IDPT in mental health were not reported. The most common information architecture used by studies was tunnel-based, although a number of studies did not report the choice of information architecture used. Rule-based strategies were the most common adaptive strategies used by these studies. All of the studies were broadly grouped into two adaptive dimensions based on user preferences or using performance measures, such as psychometric tests.

CONCLUSIONS

Several studies suggest that adaptive IDPT has the potential to enhance intervention outcomes and increase user adherence. There is a lack of studies reporting design elements, adaptive elements, and adaptive strategies in IDPT systems. Hence, focused research on adaptive IDPT systems and clinical trials to assess their effectiveness are needed.

Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis

Background

There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development.

Objective

This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom.

Methods

Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls.

Results

A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found.

Conclusions

Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects.

Trial Registration

International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184

The Influence of Three Modes of Human Support on Attrition and Adherence to a Web- and Mobile App-Based Mental Health Promotion Intervention in a Nonclinical Cohort: Randomized Comparative Study

Background

The escalating prevalence of mental health disorders necessitates a greater focus on web- and mobile app–based mental health promotion initiatives for nonclinical groups. However, knowledge is scant regarding the influence of human support on attrition and adherence and participant preferences for support in nonclinical settings.

Objective

This study aimed to compare the influence of 3 modes of human support on attrition and adherence to a digital mental health intervention for a nonclinical cohort. It evaluated user preferences for support and assessed whether adherence and outcomes were enhanced when participants received their preferred support mode.

Methods

Subjects participated in a 10-week digital mental health promotion intervention and were randomized into 3 comparative groups: standard group with automated emails (S), standard plus personalized SMS (S+pSMS), and standard plus weekly videoconferencing support (S+VCS). Adherence was measured by the number of video lessons viewed, points achieved for weekly experiential challenge activities, and the total number of weeks that participants recorded a score for challenges. In the postquestionnaire, participants ranked their preferred human support mode from 1 to 4 (S, S+pSMS, S+VCS, S+pSMS & VCS combined). Stratified analysis was conducted for those who received their first preference. Preintervention and postintervention questionnaires assessed well-being measures (ie, mental health, vitality, depression, anxiety, stress, life satisfaction, and flourishing).

Results

Interested individuals (N=605) enrolled on a website and were randomized into 3 groups (S, n=201; S+pSMS, n=202; S+VCS, n=201). Prior to completing the prequestionnaire, a total of 24.3% (147/605) dropped out. Dropout attrition between groups was significantly different (P=.009): 21.9% (44/201) withdrew from the S group, 19.3% (39/202) from the S+pSMS group, and 31.6% (64/202) from the S+VCS group. The remaining 75.7% (458/605) registered and completed the prequestionnaire (S, n=157; S+pSMS, n=163; S+VCS, n=138). Of the registered participants, 30.1% (138/458) failed to complete the postquestionnaire (S, n=54; S+pSMS, n=49; S+VCS, n=35), but there were no between-group differences (P=.24). For the 69.9% (320/458; S, n=103; S+pSMS, n=114; S+VCS, n=103) who completed the postquestionnaire, no between-group differences in adherence were observed for mean number of videos watched (P=.42); mean challenge scores recorded (P=.71); or the number of weeks that challenge scores were logged (P=.66). A total of 56 participants (17.5%, 56/320) received their first preference in human support (S, n=22; S+pSMS, n=26; S+VCS, n=8). No differences were observed between those who received their first preference and those who did not with regard to video adherence (P=.91); challenge score adherence (P=.27); or any of the well-being measures including, mental health (P=.86), vitality (P=.98), depression (P=.09), anxiety (P=.64), stress (P=.55), life satisfaction (P=.50), and flourishing (P=.47).

Conclusions

Early dropout attrition may have been influenced by dissatisfaction with the allocated support mode. Human support mode did not impact adherence to the intervention, and receiving the preferred support style did not result in greater adherence or better outcomes.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR): 12619001009101; http://www.anzctr.org.au/ACTRN12619001009101.aspx

Cost-Utility of Internet-Based Cognitive Behavioral Therapy in Unipolar Depression: A Markov Model Simulation

BACKGROUND AND OBJECTIVE

Unipolar depression is the most common form of depression and demand for treatment, such as psychotherapy, is high. However, waiting times for psychotherapy often considerably exceed their recommended maximum. As a potentially less costly alternative treatment, internet-based cognitive behavior therapy (ICBT) might help reduce waiting times. We therefore analyzed the cost-utility of ICBT compared to face-to-face CBT (FCBT) as an active control treatment, taking differences in waiting time into account.

METHODS

We constructed a Markov model to simulate costs and health outcomes measured in quality-adjusted life years (QALYs) for ICBT and FCBT in Germany. We modeled a time horizon of 3 years using six states (remission, depressed, spontaneous remission, undergoing treatment, treatment finished, death). The societal perspective was adopted. We obtained parameters for transition probabilities, depression-specific QoL, and cost data from the literature. Deterministic and probabilistic sensitivity analyses were conducted. Within a scenario analysis, we simulated different time-to-treatment combinations. Half-cycle correction was applied.

RESULTS

In our simulation, ICBT generated 0.260 QALYs and saved €2536 per patient compared to FCBT. Our deterministic sensitivity analysis suggests that the base-case results were largely unaffected by parameter uncertainty and are therefore robust. Our probabilistic sensitivity analysis suggests that ICBT is highly likely to be more effective (91.5%), less costly (76.0%), and the dominant strategy (69.7%) compared to FCBT. The scenario analysis revealed that the base-case results are robust to variations in time-to-treatment differences.

CONCLUSION

ICBT has a strong potential to balance demand and supply of CBT in unipolar depression by reducing therapist time per patient. It is highly likely to generate more QALYs and reduce health care expenditure. In addition, ICBT may have further positive external effects, such as freeing up capacities for the most severely depressed patients.

Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial

Background

Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient.

Objective

This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression.

Methods

Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)–measured depressive symptoms and time spent in treatment.

Results

Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ.

Conclusions

Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice.

Trial Registration

International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131.

Computer-Assisted CBT and Mobile Apps for Depression: Assessment and Integration Into Clinical Care

A surge in the development of computer-assisted cognitive-behavioral therapy (CCBT) and mobile apps for depression has provided many tools with potential for enhancing treatment delivery. This article assesses progress in evaluation and implementation of CCBT and mobile apps for depression, with a focus on providing practical information on clinical applications. Advantage and disadvantages of these technologies are identified, outcome research is reviewed, and recommendations are made for clinical use. With increasing use of computer technology in everyday life, it is likely that clinicians and patients will pursue opportunities to employ computer tools in treatment for depression.

The Efficacy of PowerPoint-based CBT Delivered Through Email: Breaking the Barriers to Treatment for Generalized Anxiety Disorder

OBJECTIVE

A lack of resources and cultural stigma associated with mental health treatment necessitate the development of innovative and economical individualized treatments. This study evaluated the efficacy of delivering computer-based cognitive behavioral therapy (e-CBT) presented through Microsoft PowerPoint and delivered via email in the treatment of generalized anxiety disorder (GAD) to Iranian patients, as a means of overcoming treatment barriers.

METHODS

Participants (N=80) of Iranian descent were recruited through announcements on psychology websites, Iranian organization websites, weblogs, and in flyers. Participants were randomly assigned to either an e-CBT or a control group. The e-CBT group received 12 weekly modules and homework assignments through email, presented using PowerPoint. The control group received no treatment (individuals in the control group were able to pursue another treatment, but would then be excluded from the study although they could continue with the program). All emails were sent by an attending or resident psychiatrist, who also provided feedback on weekly homework via email. The Beck Anxiety Inventory was used to measure levels of anxiety before study onset and changes in levels of anxiety upon completion of the program at 12 weeks, and at 6-month and 1-year follow-up in both groups.

RESULTS

Beck Anxiety Inventory scores were significantly reduced in the group who received PowerPoint e-CBT modules delivered via email, compared with the control group, following 12 weeks of treatment, and the reductions were maintained at both follow-up points.

CONCLUSIONS

Delivery of PowerPoint e-CBT modules via email was found to be a viable method for delivering CBT to individuals with GAD and a simple method for overcoming language, cultural, and travel barriers to accessing mental health resources. This simplified approach to the individualization and delivery of treatment modules has the potential to improve access to CBT as a treatment option throughout the world.

Efficacy of guided internet-assisted intervention on depression reduction among educational technology students of Nigerian universities

BACKGROUND/OBJECTIVE

The study's objective was to determine the efficacy of guided internet-assisted intervention (GIAI) on depression reduction among educational technology students of Nigerian universities.

METHODS

The design of the study was a 10-weeks group-randomized trial (GRT) which involved a pre-test, post-test, and follow-up assessment. A total of 192 educational technology students who were identified as having depression formed the sample of the study. Beck's Depression Inventory-II (BDI-II) was the measure used for data collection in the study. Data collected were analyzed using ANOVA with repeated measures.

RESULTS

The initial assessment results showed that the participants in both treatment and usual-care control groups had depression. After 10-weeks participation in GIAI, the assessment results showed a significant reduction in depression among students in the treatment group when compared to those in the usual-care control group. The follow-up assessment indicated a further significant reduction in the depression among participants in the treatment group when compared to those in the usual-care control group.

CONCLUSION

The authors concluded that GIAI was significantly effective in reducing depression among university students in the treatment group compared to those in the usual-care control group. Therefore, educational technologists, counselors, psychologists, health workers, and other social workers should adopt educational intervention using GIAI in helping university students undergo depression reduction.

Use of a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention in a Community Population of Adults With Depression Symptoms: Randomized Controlled Trial

Background

Although internet-based cognitive behavior therapy (iCBT) interventions can reduce depression symptoms, large differences in their effectiveness exist.

Objective

The aim of this study was to evaluate the effectiveness of an iCBT intervention called Thrive, which was designed to enhance engagement when delivered as a fully automated, stand-alone intervention to a rural community population of adults with depression symptoms.

Methods

Using no diagnostic or treatment exclusions, 343 adults with depression symptoms were recruited from communities using an open-access website and randomized 1:1 to the Thrive intervention group or the control group. Using self-reports, participants were evaluated at baseline and 4 and 8 weeks for the primary outcome of depression symptom severity and secondary outcome measures of anxiety symptoms, work and social adjustment, psychological resilience, and suicidal ideation.

Results

Over the 8-week follow-up period, the intervention group (n=181) had significantly lower depression symptom severity than the control group (n=162; P<.001), with a moderate treatment effect size (d=0.63). Moderate to near-moderate effect sizes favoring the intervention group were observed for anxiety symptoms (P<.001; d=0.47), work/social functioning (P<.001; d=0.39), and resilience (P<.001; d=0.55). Although not significant, the intervention group was 45% less likely than the control group to experience increased suicidal ideation (odds ratio 0.55).

Conclusions

These findings suggest that the Thrive intervention was effective in reducing depression and anxiety symptom severity and improving functioning and resilience among a mostly rural community population of US adults. The effect sizes associated with Thrive were generally larger than those of other iCBT interventions delivered as a fully automated, stand-alone intervention.

Trial Registration

ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878

Computer-Assisted Cognitive-Behavior Therapy and Mobile Apps for Depression and Anxiety

PURPOSE OF REVIEW

We reviewed research on computer-assisted cognitive-behavior therapy (CCBT) and mobile applications with the goals of assessing the effectiveness of these newer methods of delivering or augmenting treatment and making recommendations on the clinical use of computer tools in psychotherapy of depression and anxiety.

RECENT FINDINGS

Research on CCBT has found solid evidence for efficacy when the use of a therapeutic computer program is supported by a clinician or other helping professionals. Lower levels of efficacy or ineffectiveness typically have been found when computer programs are used as stand-alone treatments. A large number of mobile apps have been created that claim to be useful for depression and/or anxiety. However, considerable caution is warranted in evaluating mobile apps and recommending them to patients. Research on mobile apps is still in an early stage of development. A number of well-established CCBT programs have been studied in multiple randomized, controlled trials and have been found to be effective. Such programs appear to have adequate quality, security, and efficacy to be used in clinical practice. Mobile apps offer easy portability and immediate access to coping strategies and may be useful for augmenting treatment. But clinicians need to select apps with integrity and reliable content for clinical use.

Computerized Cognitive Behavioral Therapy for Treatment of Depression in Multiple Sclerosis: A Narrative Review of Current Findings and Future Directions

Depression is common in multiple sclerosis (MS), affecting up to 50% of patients at some point in their lifetime. Although the rate of depression in MS is higher than that in the general population and that in patients with other chronic medical conditions, depression in MS is underdiagnosed and undertreated. Antidepressant agents are used empirically in the management of MS-related depression, but evidence specifically demonstrating the efficacy of these medications in patients with MS is sparse. Considerable work suggests that psychological interventions such as cognitive behavioral therapy (CBT) may be effective in the management of depression in MS. Recently there has been an expansion of computerized adaptations of CBT, allowing patients to complete therapy sessions remotely via online programs. This article reviews our current understanding of depression in MS and the role of CBT in its management, focusing on recent developments in computerized formats for CBT. Four computerized CBT programs that have been previously tested in patients with MS are described: Deprexis, MoodGYM, Beating the Blues, and MS Invigor8. We conclude that despite challenges inherent to computerized CBT interventions, such platforms have the potential to positively affect mental health care delivery to the MS patient population.

Online Positive Affect Journaling in the Improvement of Mental Distress and Well-Being in General Medical Patients With Elevated Anxiety Symptoms: A Preliminary Randomized Controlled Trial

BACKGROUND

Positive affect journaling (PAJ), an emotion-focused self-regulation intervention, has been associated with positive outcomes among medical populations. It may be adapted for Web-based dissemination to address a need for scalable, evidence-based psychosocial interventions among distressed patients with medical conditions.

OBJECTIVE

This study aimed to examine the impact of a 12-week Web-based PAJ intervention on psychological distress and quality of life in general medical patients.

METHODS

A total of 70 adults with various medical conditions and elevated anxiety symptoms were recruited from local clinics and randomly assigned to a Web-based PAJ intervention (n=35) or usual care (n=35). The intervention group completed 15-min Web-based PAJ sessions on 3 days each week for 12 weeks. At baseline and the end of months 1 through 3, surveys of psychological, interpersonal, and physical well-being were completed.

RESULTS

Patients evidenced moderate sustained adherence to Web-based intervention. PAJ was associated with decreased mental distress and increased well-being relative to baseline. PAJ was also associated with less depressive symptoms and anxiety after 1 month and greater resilience after the first and second month, relative to usual care.

CONCLUSIONS

Web-based PAJ may serve as an effective intervention for mitigating mental distress, increasing well-being, and enhancing physical functioning among medical populations. PAJ may be integrated into routine medical care to improve quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01873599; https://clinicaltrials.gov/ct2/show/NCT01873599 (Archived by WebCite at http://www.webcitation.org/73ZGFzD2Z).

Are Digitally Delivered Psychological Interventions for Depression the Way Forward? A Review

Digitally delivered interventions aim to make psychological treatments more widely accessible and minimize clinician input. Although their clinical efficacy against wait-list, control conditions is well established, comparative outcome studies are a much better way to examine if psychotherapies are equally effective. Such reviews are still relatively lacking. The aim of this review was therefore to evaluate the effectiveness of digitally delivered psychological therapies over traditionally delivered (face-to-face) ones to alleviate symptoms in adults experiencing sub-threshold and clinical depression. Findings showed that digital interventions produced consistently clinically significant improvements in depressive symptoms. Moreover, the level of therapist contact or expertise did not affect much treatment effectiveness. Future research is pertinent to investigate further the influence of therapist input, the reasons for dropout, how to improve users' experience and therapeutic engagement and maintain improvements at post-treatment.

Is self-guided internet-based cognitive behavioural therapy (iCBT) harmful? An individual participant data meta-analysis

BACKGROUND

Little is known about potential harmful effects as a consequence of self-guided internet-based cognitive behaviour therapy (iCBT), such as symptom deterioration rates. Thus, safety concerns remain and hamper the implementation of self-guided iCBT into clinical practice. We aimed to conduct an individual participant data (IPD) meta-analysis to determine the prevalence of clinically significant deterioration (symptom worsening) in adults with depressive symptoms who received self-guided iCBT compared with control conditions. Several socio-demographic, clinical and study-level variables were tested as potential moderators of deterioration.

METHODS

Randomised controlled trials that reported results of self-guided iCBT compared with control conditions in adults with symptoms of depression were selected. Mixed effects models with participants nested within studies were used to examine possible clinically significant deterioration rates.

RESULTS

Thirteen out of 16 eligible trials were included in the present IPD meta-analysis. Of the 3805 participants analysed, 7.2% showed clinically significant deterioration (5.8% and 9.1% of participants in the intervention and control groups, respectively). Participants in self-guided iCBT were less likely to deteriorate (OR 0.62, p < 0.001) compared with control conditions. None of the examined participant- and study-level moderators were significantly associated with deterioration rates.

CONCLUSIONS

Self-guided iCBT has a lower rate of negative outcomes on symptoms than control conditions and could be a first step treatment approach for adult depression as well as an alternative to watchful waiting in general practice.

Benefits of Individualized Feedback in Internet-Based Interventions for Depression: A Randomized Controlled Trial

BACKGROUND

Even though there is an increasing number of studies on the efficacy of Internet-based interventions (IBI) for depression, experimental trials on the benefits of added guidance by clinicians are scarce and inconsistent. This study compared the efficacy of semistandardized feedback provided by psychologists with fully standardized feedback in IBI.

METHODS

Participants with mild-to-moderate depression (n = 1,089, 66% female) from the client pool of a health insurance company participated in a cognitive-behavioral IBI targeting depression over 6 weeks. Individuals were randomized to weekly semistandardized e-mail feedback from psychologists (individual counseling; IC) or to automated, standardized feedback where a psychologist could be contacted on demand (CoD). The contents and tasks were identical across conditions. The primary outcome was depression; secondary outcomes included anxiety, rumination, and well-being. Outcomes were assessed before and after the intervention and 3, 6, and 12 months later. Changes in outcomes were evaluated using latent change score modeling.

RESULTS

Both interventions yielded large pre-post effects on depression (Beck Depression Inventory-II: dIC = 1.53, dCoD = 1.37; Patient Health Questionnaire-9: dIC = 1.20, dCoD = 1.04), as well as significant improvements of all other outcome measures. The effects remained significant after 3, 6, and 12 months. The groups differed with regard to attrition (IC: 17.3%, CoD: 25.8%, p = 0.001). Between-group effects were statistically nonsignificant across outcomes and measurement occasions.

CONCLUSION

Adding semistandardized guidance in IBI for depression did not prove to be more effective than fully standardized feedback on primary and secondary outcomes, but it had positive effects on attrition.

Efficacy of cognitive behavioural therapy delivered over the Internet for depressive symptoms: A systematic review and meta-analysis

Introduction Cognitive behavioural therapy has been shown to improve depressive symptoms in adults with mild to moderate depression. To overcome many of the barriers associated with delivering this treatment, attempts have been made to deliver cognitive behavioural therapy via the Internet. The objective of this meta-analysis is to assess whether Internet-based cognitive behavioural therapy delivered to adults with depressive symptoms leads to a reduction in these symptoms as compared to those who receive no therapy. Methods In September 2015, the Cochrane, PubMed and PsycInfo databases were searched; studies were also found through bibliography searches. Studies were included if they were randomized controlled trials published in English between 2005-2015 conducted with adults >18 years of age experiencing mild to moderate depression where study subjects received Internet-based cognitive behavioural therapy, and the control group was placed on a wait-list. The search yielded 257 articles; 14 of these were included in the meta-analysis. Results Internet delivered cognitive behavioural therapy had a medium effect on reducing depressive symptoms at the end of the study period (standardized mean difference: 0.74, confidence interval: 0.62-0.86, p < 0.001). Internet-delivered cognitive behavioural therapy also has a large sustained effect in maintaining reduction of depressive symptoms in follow-up measures done 3-6 months after the conclusion of the therapy (standardized mean difference: 0.83, confidence interval: 0.69-0.99, p < 0.001). There was no publication bias and low heterogeneity. Discussion Cognitive behavioural therapy delivered over the Internet leads to immediate and sustained reduction in depressive symptoms; thus, it may be a good treatment modality for individuals unable or unwilling to access traditional face-to-face therapy.

Breaking Away: The Role of Homeostatic Drive in Perpetuating Depression

We propose that the complexity of regulatory interactions modulating brain neurochemistry and behavior is such that multiple stable responses may be supported, and that some of these alternate regulatory programs may play a role in perpetuating persistent psychological dysfunction. To explore this, we constructed a model network representing major neurotransmission and behavioral mechanisms reported in literature as discrete logic circuits. Connectivity and information flow through this biobehavioral circuitry supported two distinct and stable regulatory programs. One such program perpetuated a depressive state with a characteristic neurochemical signature including low serotonin. Further analysis suggested that small irregularities in glutamate levels may render this pathology more directly accessible. Computer simulations mimicking selective serotonin reuptake inhibitor (SSRI) therapy in the presence of everyday stressors predicted recidivism rates similar to those reported clinically and highlighted the potentially significant benefit of concurrent behavioral stress management therapy.

Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial

BACKGROUND

The evidence for the effectiveness of Web-based therapies comes mainly from nonclinical populations, with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. Adherence to Web-based therapies is often poor. One way to increase this is to create a new health service role of a coach to guide people through the therapy.

OBJECTIVE

This study aimed to test in people referred to secondary care with depression if a Web-based therapy (The Journal) supported by a coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about Web-based resources after 12 weeks.

METHODS

We conducted a randomized controlled trial with two parallel arms and a process evaluation that included structured qualitative interviews analyzed using thematic analysis. The coach had a background in occupational therapy. Participants were recruited face-to-face at community mental health centers.

RESULTS

We recruited 63 people into the trial (intervention 35, control 28). There were no statistically significant differences in the change from baseline in Patient Health Questionnaire-9 (PHQ-9) scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group, t₄₁=1.05, P=.30; mean difference=2.3, 95% CI -2.1 to 6.7). People who were offered The Journal attended on average about one less outpatient appointment compared with usual care, although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group, t₄₅=-0.80, P=.43; mean difference=1.3, 95% CI -4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 (SD=1.9; range=0-6) and the number of contacts with the coach was a mean of 8.1 (SD=4.4; range=0-17). The qualitative interviews highlighted the problem of engaging clinicians in research and their resistance to recruitment: technical difficulties with The Journal, which prevented people logging in easily; difficulty accessing The Journal as it was not available on mobile devices; participants finding some lessons difficult; and participants saying they were too busy to complete the sessions.

CONCLUSIONS

The study demonstrated that it is feasible to use a coach in this setting, that people found it helpful, and that it did not conflict with other care that participants were receiving. Future trials need to engage clinicians at an early stage to articulate where Web-based therapies fit into existing clinical pathways; Web-based therapies should be available on mobile devices, and logging in should be easy. The role of the coach should be explored in larger trials.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN): 12613000015741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363351&isReview=true (Archived by WebCite at http://www.webcitation.org/6wEyCc6Ss).

[Can we do therapy without a therapist? Active components of computer-based CBT for depression]

OBJECTIVES

Computer-delivered Cognitive Behavioral Therapies (C-CBT) are emerging as therapeutic techniques which contribute to overcome the barriers of health care access in adult populations with depression. The C-CBTs provide CBT techniques in a highly structured format comprising a number of educational lessons, homework, multimedia illustrations and supplementary materials via interactive computer interfaces. Programs are often administrated with a minimal or regular support provided by a clinician or a technician via email, telephone, online forums, or during face-to-face consultations. However, a lot of C-CBT is provided without any therapeutic support. Several reports showed that C-CBTs, both guided or unguided by a therapist, may be reliable and effective for patients with depression, and their use was recommended as part of the first step of the clinical care. The aim of the present qualitative review is to describe the operational format and functioning of five of the most cited unguided C-CBT programs for depression, to analyze their characteristics according to the CBT's principles, and to discuss the results of the randomized clinical trials (RCT) conducted to evaluate its effectiveness, adherence and user's experience.

METHODS

We analyzed five C-CBTs: Beating The Blues (BTB), MoodGYM, Sadness, Deprexis and Overcoming Depression on the Internet (ODIN) and 22 randomized controlled studies according to 5 dimensions: General characteristics; Methodology, structure and organization; Specific modules, themes and techniques: Clinical indications, recruitment mode, type of users with depression, type and mode of therapist's support, overall therapeutic effects, adherence and user's experience.

RESULTS

The C-CBT have a secured free or pay-to-use access in different languages (English, German, Dutch, and Chinese) but not in French. The programs may be accessed at a medical center or at home via a CD-ROM or via an Internet connection. Some C-CBTs are very close to textual self-helps provided via an E-learning mode (Sadness, MoodGYM, ODIN), others adopt interactive software technologies (Deprexis, BTB), but their interactivity and the possibility of personalization is low. The C-CBTs use similar principles and techniques as in face-to -face CBT (e.g. self-evaluation, psychoeducation, cognitive restructuring, cognitive restructuring of schema, behavioral activation and agenda setting, problem solving techniques, communication and crisis management techniques, relaxation, principles of positive psychology and relapse prevention, positive reinforcement methods, motivational feedbacks, social learning, homework assignments and progress monitoring). The results of the 22 RCSs showed that both the effectiveness and the adherence of the unguided C-CBT is high with self-referred active help-seekers with major depression, but the latter is low with users who are depressed out-patients referred by general practitioners or clinicians. The presence of therapist support improves the effectiveness and the adherence of the C-CBT, especially in clinical out-patients.

CONCLUSIONS

In light of the existing insight of the advantages and the inconvenient of the C-CBT, the actual challenge is to find its optimal clinical indication and the modality of its effective use in clinical populations.

Impact of telephone prompts on the adherence to an Internet-based aftercare program for women with bulimia nervosa: A secondary analysis of data from a randomized controlled trial

INTRODUCTION

Poor adherence is a common challenge in self-directed mental health interventions. Research findings indicate that telephone prompts may be useful to increase adherence.

METHOD

Due to poor adherence in a randomized controlled trial evaluating an Internet-based aftercare program for women with bulimia nervosa we implemented regular short telephone prompts into the study protocol halfway through the trial period. Of the 126 women in the intervention group, the first 63 women were not prompted by telephone (unprompted group) and compared with 63 women who subsequently enrolled into the study and were attempted to prompt bimonthly by a research assistant (telephone prompt group). Completed telephone calls took less than 5 min and did not include any symptom-related counseling.

RESULTS

Most of the women in the telephone prompt group (67%) were reached only once or twice during the intervention period. However, overall adherence in the telephone prompt group was significantly higher than in the unprompted group (T = - 3.015, df = 124, p = 0.003).

CONCLUSION

Our findings from this secondary analysis suggest that telephone prompts can positively affect adherence to an Internet-based aftercare intervention directed at patients with bulimia nervosa.

A scoping review of human-support factors in the context of Internet-based psychological interventions (IPIs) for depression and anxiety disorders

Internet-based psychological interventions (IPIs) may provide a highly accessible alternative to in-person psychotherapy. However, little is known about the role of human-support in IPIs for depression and anxiety disorders. The purpose of this study was to evaluate the evidence in the literature regarding the role of human-support in IPIs for depression and anxiety disorders; identify research gaps; and provide recommendations. A scoping review of randomized controlled trials was conducted using seven databases. Two reviewers screened citations, selected studies, and extracted data. Data was analyzed and summarized by common human-support factors. Seven categories for support factors were identified from 19 studies: guided versus unguided IPIs, level of therapist expertise, human versus automated support, scheduled versus unscheduled contact, mode of communication, synchronicity of communication, and intensity of support. Only one feature had a significant effect on treatment outcomes, with scheduled support resulting in better outcomes than unscheduled support. There were mixed findings regarding guided versus unguided interventions and human versus automated support. Providing structured support in a fixed-interval schedule is recommended to enhance the utilization of IPIs for depression and anxiety disorders. Findings should be interpreted with caution due to the limited available research. Further research is needed to draw robust conclusions.

Internet interventions for depression: new developments

A wide range of Internet interventions, mostly grounded in methods of cognitive behavioral therapy, have been developed and tested for several mental disorders. The evidence to date shows that these interventions are effective in reducing symptoms of depression. Metaanalyses report small-to-medium effect sizes when Internet interventions are delivered as stand-alone self-help interventions (d=0.25-0.36), and medium-to-large effect sizes when delivered as therapist-guided interventions (d=0.58-0.78), both compared with usual care. Only a minority of people suffering from depression receive adequate treatment, and Internet interventions might help bridge the large treatment gap. This review summarizes the current body of evidence and highlights pros and cons of Internet interventions. It also outlines how they could be implemented in mental health care systems and points out unresolved questions, as well as future directions, in this research field.