Common practices for sociodemographic data reporting in digital mental health intervention research: a scoping review

BACKGROUND

The ability of digital mental health interventions (DMHIs) to reduce mental health disparities relies on the recruitment of research participants with diverse sociodemographic and self-identity characteristics. Despite its importance, sociodemographic reporting in research is often limited, and the state of reporting practices in DMHI research in particular has not been comprehensively reviewed.

OBJECTIVES

To characterise the state of sociodemographic data reported in randomised controlled trials (RCTs) of app-based DMHIs published globally from 2007 to 2022.

METHODS

A scoping review of RCTs of app-based DMHIs examined reporting frequency for 16 sociodemographic domains (eg, gender) and common category options within each domain (eg, woman). The search queried five electronic databases. 5079 records were screened and 299 articles were included.

RESULTS

On average, studies reported 4.64 (SD=1.79; range 0-9) of 16 sociodemographic domains. The most common were age (97%) and education (67%). The least common were housing situation (6%), residency/location (5%), veteran status (4%), number of children (3%), sexual orientation (2%), disability status (2%) and food security (<1%). Gender or sex was reported in 98% of studies: gender only (51%), sex only (28%), both (<1%) and gender/sex reported but unspecified (18%). Race or ethnicity was reported in 48% of studies: race only (14%), ethnicity only (14%), both (10%) and race/ethnicity reported but unspecified (10%).

CONCLUSIONS

This review describes the widespread underreporting of sociodemographic information in RCTs of app-based DMHIs published from 2007 to 2022. Reporting was often incomplete (eg, % female only), unclear (eg, the conflation of gender/sex) and limited (eg, only options representing majority groups were reported). Trends suggest reporting has somewhat improved in recent years. Diverse participant populations must be welcomed and described in DMHI research to broaden learning and the generalisability of results, a prerequisite of DMHI's potential to reduce disparities in mental healthcare.

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study

BACKGROUND

Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS).

OBJECTIVE

We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS.

METHODS

A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study.

RESULTS

The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms.

CONCLUSIONS

The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

Analysis of Caregiver Burden Expressed in Social Media Discussions

Almost 40% of US adults provide informal caregiving, yet research gaps remain around what burdens affect informal caregivers. This study uses a novel social media site, Reddit, to mine and better understand what online communities focus on as their caregiving burdens. These forums were accessed using an application programming interface, a machine learning classifier was developed to remove low information posts, and topic modeling was applied to the corpus. An expert panel summarized the forums' themes into ten categories. The largest theme extracted from Reddit's forums discussed the personal emotional toll of being a caregiver. This was followed by logistic issues while caregiving and caring for parents who have cancer. Smaller themes included approaches to end-of-life care, physical equipment needs when caregiving, and the use of wearables or technology to help monitor care recipients. The platform often discusses caregiving for parents which may reflect the age of Reddit's users. This study confirms that Reddit forums are used for caregivers to discuss the burdens associated with their role and the types of stress that can result from informal caregiving.

Promoting benzodiazepine cessation through an electronically-delivered patient self-management intervention (EMPOWER-ED): Randomized controlled trial protocol

Background

Long-term benzodiazepine dependence carries significant health risks which might be reduced with low-cost patient self-management interventions. A booklet version of one such intervention (Eliminating Medications Through Patient Ownership of End Results; EMPOWER) proved effective in a Canadian clinical trial with older adults. Digitizing such an intervention for electronic delivery and tailoring it to different populations could expand its reach. Accordingly, this article describes the protocol for a randomized controlled trial to test the effectiveness of an electronically-delivered, direct-to-patient benzodiazepine cessation intervention tailored to U.S. military veterans.

Methods

Design: Two-arm individually randomized controlled trial.

Setting

US Veterans Health Administration primary care clinics.

Participants

Primary care patients taking benzodiazepines for three or more months and having access to a smartphone, tablet or desktop computer.

Intervention and comparator

Participants will be randomized to receive either the electronically-delivered EMPOWER (EMPOWER-ED) protocol or asked to continue to follow provider recommendations regarding their benzodiazepine use (treatment-as-usual).

Measurements

The primary outcomes are complete benzodiazepine cessation and 25% dose reduction, assessed using administrative and self-report data, between baseline and six-month follow-up. Secondary outcomes are self-reported anxiety symptoms, sleep quality, and overall health and quality of life, measured at baseline and 6-month follow-up, and benzodiazepine cessation at 12-month follow-up.

Comments

This randomized controlled trial will evaluate whether the accessibility and effectiveness of a promising intervention for benzodiazepine cessation can be improved through digitization and population tailoring.

What's in Between the Lines: Assessing the Readability, Understandability, and Actionability in Breast Cancer Survivorship Print Materials

Educational print materials for young women breast cancer survivors (YBCS) are supplemental tools used in patient teaching. However, the readability of the text coupled with how well YBCS understand or act upon the material are rarely explored. The purpose of this study was to assess the readability, understandability, and actionability of commonly distributed breast cancer survivorship print materials. We used an environmental scan approach to obtain a sample of breast cancer survivorship print materials available in outpatient oncology clinics in the central region of a largely rural Southern state. The readability analyses were completed using the Flesch-Kincaid (F-K), Fry Graph Readability Formula (Fry), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were analyzed using Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). The environmental scan resulted in a final sample of 14 materials. The mean readability of the majority of survivorship materials was "difficult," but the majority scored above the recommended 70% in both understandability and actionability. The importance of understandability and actionability may outweigh readability results in cancer education survivorship material. While reading grade level cannot be dismissed all together, we surmise that patient behavior may hinge more on other factors such as understandability and actionability. Personalized teaching accompanying print material may help YBCS comprehend key messages and promote acting upon specific tasks.

Enhancing Problem-Solving Therapy With Smartphone Technology: A Pilot Randomized Controlled Trial

OBJECTIVE

Development of smartphone apps for mental health care has outpaced research on their effectiveness. This pilot study tested Moving Forward, an app designed to support problem-solving therapy (PST).

METHODS

Thirty-three veterans seeking mental health care in U.S. Department of Veterans Affairs primary care clinics were randomly assigned to receive six sessions of PST accompanied by either the Moving Forward app (N=17) or a workbook (N=16). Participants completed measures of anxiety, depression, stress, problem-solving style, satisfaction, and between-session practice at baseline and 6- and 12-week follow-ups. Qualitative interviews were used to elicit feedback.

RESULTS

Participants in both groups reported high satisfaction and reductions in depression, anxiety, and stress. Veterans who used the app reported skills practice, and qualitative data indicated that patients perceived the app as valuable, with the potential to reduce barriers to care.

CONCLUSIONS

This study provides preliminary evidence to support the ability of the Moving Forward app to augment brief psychotherapy in primary care clinics.

Targeting subjective engagement in experimental therapeutics for digital mental health interventions

Engagement is a multifaceted construct and a likely mechanism by which digital interventions achieve clinical improvements. To date, clinical research on digital mental health interventions (DMHIs) has overwhelmingly defined engagement and assessed its association with clinical outcomes through the objective/behavioral metrics of use of or interactions with a DMHI, such as number of log-ins or time spent using the technology. However, engagement also entails users' subjective experience. Research is largely lacking that tests the relationship between subjective metrics of engagement and clinical outcomes. The purpose of this study is to present a proof-of-concept exploratory evaluation of the association between subjective engagement measures of a mobile DMHI with changes in depression and anxiety. Adult primary care patients (N = 146) who screened positive for depression or anxiety were randomized to receive a DMHI, IntelliCare, immediately or following an 8-week waitlist. Subjective engagement was measured via the Usefulness, Satisfaction, and Ease of Use (USE) Questionnaire. Across both conditions, results showed that individuals who perceived a mobile intervention as more useful, easy to use and learn, and satisfying had greater improvements in depression and anxiety over eight weeks. Findings support our proposed experimental therapeutics framework that hypothesizes objective/behavioral and subjective engagement metrics as mechanisms that lead to changes in clinical outcomes, as well as support directing intervention design efforts for DMHIs to target the user experience.

Lessons learned from service design of a trial of a digital mental health service: Informing implementation in primary care clinics

Implementing a digital mental health service in primary care requires integration into clinic workflow. However, without adequate attention to service design, including designing referral pathways to identify and engage patients, implementation will fail. This article reports results from our efforts designing referral pathways for a randomized clinical trial evaluating a digital service for depression and anxiety delivered through primary care clinics. We utilized three referral pathways: direct to consumer (e.g., digital and print media, registry emails), provider referral (i.e., electronic health record [EHR] order and provider recommendation), and other approaches (e.g., presentations, word of mouth). Over the 5-month enrollment, 313 individuals completed the screen and reported how they learned about the study. Penetration was 13%, and direct to consumer techniques, most commonly email, had the highest yield. Providers only referred 16 patients through the EHR, half of whom initiated the screen. There were no differences in referral pathway based on participants' age, depression severity, or anxiety severity at screening. Ongoing discussions with providers revealed that the technologic implementation and workflow design may not have been optimal to fully affect the EHR-based referral process, which potentially limited patient access. Results highlight the importance of designing and evaluating referral pathways within service implementation, which is important for guiding the implementation of digital services into practice. Doing so can ensure that sustained implementation is not left to post-evaluation bridge-building. Future efforts should assess these and other referral pathways implemented in clinical practice outside of a research trial.

Coached Mobile App Platform for the Treatment of Depression and Anxiety Among Primary Care Patients: A Randomized Clinical Trial

Importance

Depression and anxiety are common and disabling. Primary care is the de facto site for treating these mental health problems but is typically underresourced to meet the burden of these demands.

Objective

To evaluate the efficacy of a mobile intervention platform, IntelliCare, for addressing depression and anxiety among primary care patients.

Design, Setting, and Participants

Two-arm randomized clinical trial at internal medicine clinics at the University of Arkansas for Medical Sciences. Adult primary care patients (N = 146) who screened positive for depression on the Patient Health Questionnaire-8 (PHQ; score  ≥ 10) or anxiety on the Generalized Anxiety Disorder-7 (GAD-7; score ≥ 8) were recruited between July 17, 2018, and December 14, 2018.

Interventions

The coach-supported platform composed of a suite of apps, was delivered over 8 weeks. Wait list control participants received treatment as usual for 8 weeks, then the mobile platform.

Main Outcomes and Measures

Primary outcomes were changes in depression (PHQ-9) and anxiety (GAD-7) during the intervention period. Secondary outcomes were differences in the proportion of patients who achieved recovery (PHQ-9/GAD-7 <5 or 50% improvement from baseline), sustainment of intervention effects during 2-month follow-up, and app use during the intervention period.

Results

One hundred forty-six patients were included (119 of 146 were women [81.5%]; mean [SD] age, 42.3 [13.8] years). Of the 146 patients, 122 (83.6%) were diagnosed as having depression and 131 (89.7%) were diagnosed as having anxiety. A greater proportion of intervention vs wait list control participants achieved recovery from depression (n = 38 of 64 [59%] vs n = 18 of 58 [31%]; odds ratio, 3.25; 95% CI, 1.54-6.86) and anxiety (n = 37 of 65 [57%] vs n = 25 of 66 [38%]; odds ratio, 2.17; 95% CI, 1.08-4.36). Sustained effects were observed for depression (slope, 0.01; 95% CI, -0.09 to 0.10; P = .92) and anxiety scores (slope, 0.02; 95% CI, -0.08 to 0.12; P = .67) during follow-up. App use was high, with a median of 93 and 98 sessions among participants with depression and anxiety, respectively.

Conclusions and Relevance

In this trial, a mobile intervention app was effective for depression and anxiety among primary care patients. Findings also support designing digital mental health interventions as platforms containing simple, brief apps that can be bundled by users to meet their needs.

Trial Registration

ClinicalTrials.gov Identifier: NCT03500536.

Engagement and Clinical Improvement Among Older Adult Primary Care Patients Using a Mobile Intervention for Depression and Anxiety: Case Studies

BACKGROUND

Technology-based mental health interventions are an increasingly attractive option for expanding access to mental health services within the primary care system. Older adults are among the groups that could potentially benefit from the growing ubiquity of technology-based mental health interventions; however, older adults are perceived to be averse to using technology and have reported barriers to use.

OBJECTIVE

The aim of this paper is to present a case study of 3 participants from a clinical trial evaluating IntelliCare, an evidence-based mobile intervention for depression and anxiety, among adults recruited from primary care clinics. Our report of these 3 participants, who were aged 60 years or older, focuses on their engagement with the IntelliCare service (ie, app use, coach communication) and clinical changes in depression or anxiety symptoms over the intervention period.

METHODS

The 3 case study participants were offered IntelliCare with coaching for 8 weeks. The intervention consisted of 5 treatment intervention apps that support a variety of psychological skills, a Hub app that contained psychoeducational content and administered weekly assessments, and coaching for encouragement, accountability, and technical assistance as needed. The 3 case study participants were selected to reflect the overall demographics of participants within the trial and because their interactions with IntelliCare provided a good illustration of varied experiences regarding engagement with the intervention.

RESULTS

The 3 participants' unique experiences with the intervention are described. Despite potential barriers and experiencing some technical glitches, the participants showed proficient ability to use the apps, high levels of participation through frequent app use and coach interaction, and decreased depression and anxiety scores. At the end of the 8-week intervention, each of these 3 participants expressed great enthusiasm for the benefit of this program through feedback to their coach, and they each identified a number of ways they had seen improvements in themselves.

CONCLUSIONS

These 3 cases provide examples of older individuals who engaged with and benefitted from the IntelliCare service. Although the results from these 3 cases may not generalize to others, they provide an important, informed perspective of the experiences that can contribute to our understanding of how older adults use and overcome barriers to mental health technologies. The findings also contribute toward the ultimate goal of ensuring that the IntelliCare intervention is appropriate for individuals of all ages.

Advances in PTSD Treatment Delivery: Review of Findings and Clinical Considerations for the Use of Telehealth Interventions for PTSD

Purpose of review

Effective treatments for posttraumatic stress disorder (PTSD) remain underutilized and individuals with PTSD often have difficulty accessing care. Telehealth, particularly clinical videoconferencing (CVT), can overcome barriers to treatment and increase access to care for individuals with PTSD. The purpose of this review is to summarize the literature on the delivery of PTSD treatments through office-based and home-based videoconferencing, and outline areas for future research.

Recent findings

Evidence-based PTSD treatments delivered through office-based and home-based CVT have been studied in pilot studies, non-randomized trials, and randomized clinical trials. The studies have consistently demonstrated feasibility and acceptability of these modalities as well as significant reduction in PTSD symptoms, non-inferior outcomes, and comparable dropout rates when compared with traditional face-to-face office-based care. Finally, it has been shown that using CVT does not compromise the therapeutic process.

Summary

Office-based and home-based CVT can be used to deliver PTSD treatments while retaining efficacy and therapeutic process. The use of these modalities can increase the number of individuals that can access efficacious PTSD care.

An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD

OBJECTIVE

This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD).

METHODS

In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months.

RESULTS

Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ²=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance.

CONCLUSIONS

TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.

Telehealth and eHealth interventions for posttraumatic stress disorder

This paper presents existing research describing how telehealth and eHealth technologies can be used to improve mental health services for trauma survivors, either by enhancing existing treatment approaches or as a stand-alone means of delivering trauma-relevant information and interventions. The potential ways in which telemedicine technologies aide in overcoming barriers to care is first addressed in terms of providing mental health treatment. We then outline how different telehealth and eHealth tools can be used for key therapeutic tasks, including the provision of self-guided interventions, remote delivery of psychotherapy, and augmentation of psychological treatments. We conclude by discussing key emergent issues that are shaping current and future use of telemedicine technologies as part of the continuum of care for trauma survivors.

New Electronic Tools for Veterans

The US Department of Veterans Affairs, in partnership with the Department of Defense, has developed a host of new electronic tools designed to address the mental and behavioral health needs of military service members and veterans. These tools include online self-help programs and companion mobile apps, as well as many of the apps available through the VA App Store. This commentary provides a brief overview of these new tools and discusses some of the ways in which physicians and other medical providers in North Carolina can incorporate these tools into their work with veterans.

Peeking into the black box: mechanisms of action for anger management treatment

We investigated potential mechanisms of action for anger symptom reductions, specifically, the roles of anger regulation skills and therapeutic alliance on changes in anger symptoms, following group anger management treatment (AMT) among combat veterans with posttraumatic stress disorder (PTSD). Data were drawn from a published randomized controlled trial of AMT conducted with a racially diverse group of 109 veterans with PTSD and anger symptoms residing in Hawaii. Results of latent growth curve models indicated that gains in calming skills predicted significantly larger reductions in anger symptoms at post-treatment, while the development of cognitive coping and behavioral control skills did not predict greater symptom reductions. Therapeutic alliance had indirect effects on all outcomes mostly via arousal calming skills. Results suggest that generalized symptom reduction may be mediated by development of skills in calming physiological arousal. In addition, arousal reduction skills appeared to enhance one's ability to employ other anger regulation skills.

Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial

OBJECTIVE

To compare clinical and process outcomes of cognitive processing therapy-cognitive only version (CPT-C) delivered via videoteleconferencing (VTC) to in-person in a rural, ethnically diverse sample of veterans with posttraumatic stress disorder (PTSD).

METHOD

A randomized clinical trial with a noninferiority design was used to determine if providing CPT-C via VTC is effective and "as good as" in-person delivery. The study took place between March 2009 and June 2013. PTSD was diagnosed per DSM-IV. Participants received 12 sessions of CPT-C via VTC (n = 61) or in-person (n = 64). Assessments were administered at baseline, midtreatment, immediately posttreatment, and 3 and 6 months posttreatment. The primary clinical outcome was posttreatment PTSD severity, as measured by the Clinician-Administered PTSD Scale.

RESULTS

Clinical and process outcomes found VTC to be noninferior to in-person treatment. Significant reductions in PTSD symptoms were identified at posttreatment (Cohen d = 0.78, P < .05) and maintained at 3- and 6-month follow-up (d = 0.73, P < .05 and d = 0.76, P < .05, respectively). High levels of therapeutic alliance, treatment compliance, and satisfaction and moderate levels of treatment expectancies were reported, with no differences between groups (for all comparisons, F < 1.9, P > .17).

CONCLUSIONS

Providing CPT-C to rural residents with PTSD via VTC produced outcomes that were "as good as" in-person treatment. All participants demonstrated significant reductions in PTSD symptoms posttreatment and at follow-up. Results indicate that VTC can offer increased access to specialty mental health care for residents of rural or remote areas.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00879255.

Predictors of anger treatment outcomes

OBJECTIVE

This study investigated predictors of therapeutic outcomes for veterans who received treatment for dysregulated anger.

METHOD

Data are from a randomized controlled trial investigating the effectiveness of video teleconferencing compared to in-person delivery of anger management therapy (AMT) among 125 military veterans. Multilevel modeling was used to assess 2 types of predictors (demographic characteristics and mental health factors) of changes in anger symptoms after treatment.

RESULTS

Results showed that while veterans benefited similarly from treatment across modalities, veterans who received two or more additional mental health services and who had longer commutes to care showed the greatest improvement on a composite measure of self-reported anger symptoms.

CONCLUSION

Results highlight that veterans with a range of psychosocial and mental health characteristics benefited from AMT, while those receiving the most additional concurrent mental health services had better outcomes.

Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD

BACKGROUND

Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem.

MATERIALS AND METHODS

This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery.

RESULTS

The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed.

CONCLUSIONS

The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.

Current trends in using Internet and mobile technology to support the treatment of substance use disorders

ISSUES

By allowing for the efficient delivery of instructional content and the secure collection of self-report data regarding substance use and related problems, the Internet has tremendous potential to improve the effectiveness and accessibility of Substance Use Disorder (SUD) treatment and recovery-oriented services.

APPROACH

This article discusses some of the ways in which Internet and mobile technology can facilitate, complement and support the process of traditional clinician-delivered treatment for individuals with SUDs.

KEY FINDINGS

Internet applications are being used to support a range of activities including (a) the assessment and feedback process that constitutes a key feature of brief motivational interventions; and (b) the concurrent monitoring of patients who are receiving treatment for SUDs, to support continuing care, and the ongoing recovery of SUD patients who have completed face-to-face treatment. Internet technology is also being used to (c) support efficient delivery of clinical training in evidence-based practices for treating individuals who may have SUDs.

IMPLICATIONS

This emerging body of literature suggests that SUD treatment providers and program administrators can enhance the quality of clinician-delivered treatment by incorporating internet applications into existing processes of care and recovery oriented services.

CONCLUSION

Internet applications provide an unparalleled opportunity to engage patients in the treatment process, incorporate real-time data into treatment planning, prevent relapse, and promote evidence-based treatment approaches.

Tailoring disaster mental health services to diverse needs: an analysis of 36 crisis counseling projects

The federal Crisis Counseling Program (CCP) funds states' delivery of mental health services after disasters. These services are provided by social workers, other mental health professionals, and paraprofessionals from the local community. The present study examined whether CCP grant recipients that reported more tailoring of their interventions to the needs of diverse community segments achieved greater community penetration. The study reviewed archival records from 36 crisis counseling projects ending between 1996 and 2001. Numbers of clients and client ethnicity were determined through service logs. Tailoring ofservices was determined by content coding of projects' reports. Community demographics were determined from census data. Fifty-six percent of the projects reported using three or more tailoring strategies, suggesting a "precompetence" or greater stage of cultural competence. The proportion of members of racial or ethnic minority groups among program clients closely matched the proportion in grantees' communities. Projects that reported more types of tailored activities reached more clients and served more members ofminority groups. These findings confirm that adapting crisis counseling services to diverse local needs is associated with greater community penetration of mental health services.

Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial

OBJECTIVE

To demonstrate the noninferiority of a telemedicine modality, videoteleconferencing, compared to traditional in-person service delivery of a group psychotherapy intervention for rural combat veterans with posttraumatic stress disorder (PTSD).

METHOD

A randomized controlled noninferiority trial of 125 male veterans with PTSD (according to DSM criteria on the Clinician-Administered PTSD Scale) and anger difficulties was conducted at 3 Veterans Affairs outpatient clinics. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n = 64) or via videoteleconferencing (n = 61). Participants were assessed at baseline, midtreatment (3 weeks), posttreatment (6 weeks), and 3 and 6 months posttreatment. The primary clinical outcome was reduction of anger difficulties, as measured by the anger expression and trait anger subscales of the State-Trait Anger Expression Inventory-2 (STAXI-2) and by the Novaco Anger Scale total score (NAS-T). Data were collected from August 2005 to October 2008.

RESULTS

Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with posttreatment and 3 and 6 months posttreatment effect sizes ranging from .12 to .63. Using a noninferiority margin of 2 points for STAXI-2 subscales anger expression and trait anger and 4 points for NAS-T outcomes, participants in the videoteleconferencing condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on process variables, including attrition, adherence, satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance.

CONCLUSIONS

Clinical and process outcomes indicate delivering cognitive-behavioral group treatment for PTSD-related anger problems via videoteleconferencing is an effective and feasible way to increase access to evidence-based care for veterans residing in rural or remote locations.

Issues in the design of a randomized noninferiority clinical trial of telemental health psychotherapy for rural combat veterans with PTSD

This methodological article provides a description of the design, methods, and rationale of the first prospective, noninferiority designed randomized clinical trial evaluating the clinical and cost implications of delivering an evidence-based cognitive-behavioral group intervention specifically treating posttraumatic stress disorder (PTSD) with a trauma-focused intervention via video teleconferencing (VTC). PTSD is a prevalent mental health problem found among returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) military populations. These returning military personnel often live in rural areas and therefore have limited access to care and specialized psychological treatments. In the field of mental health, telemental health (TMH) technology has introduced a potential solution to the persistent problem of access to care in remote areas. This study is enrolling approximately 126 returning veterans with current combat-related PTSD who are receiving services through the Veteran Administration (VA) mental health care clinics on 4 Hawaiian Islands. Cognitive Processing Therapy (CPT), an empirically supported manualized treatment for PTSD, is being delivered across 9 cohorts. Participants are assigned to either the experimental VTC condition or the in-person control condition. Assessments measuring clinical, process, and cost outcomes are being conducted at baseline, mid-treatment, post-treatment, and 3 and 6 months post-treatment. The study employs a noninferiority design to determine if the group treatment delivered via VTC is as good as the traditional in-person modality. In addition, a cost analysis will be performed in order to compare the cost of the 2 modalities. Novel aspects of this trial and specific challenges are discussed.

Noninferiority and equivalence designs: issues and implications for mental health research

The terms noninferiority and equivalence are often used interchangeably to refer to trials in which the primary objective is to show that a novel intervention is as effective as the standard intervention. The use of these designs is becoming increasingly relevant to mental health research. Despite the fundamental importance of these designs, they are often poorly understood, improperly applied, and subsequently misinterpreted. In this article, the authors explain noninferiority and equivalence designs and key methodological and statistical considerations. Decision points in using these designs are discussed, such as choice of control condition, determination of the noninferiority margin, and calculation of sample size and power. With increasing utilization of these designs, it is critical that researchers understand the methodological issues, advantages, disadvantages, and related challenges.

Mutagenicity monitoring in humans by autoradiographic assay for mutant T lymphocytes

Somatic cell mutation which occurs in vivo in humans can be determined by measurement of the frequency of the 6-thioguanine-resistant (TGr) T lymphocytes in samples of peripheral blood. This frequency can be determined by either a short-term autoradiographic methodology or a longer cell-cloning methodology. The advantage of the former is the relative simplicity of the assay, while the latter allows recovery of mutant clones for further characterization. This report presents results of a longitudinal study of cancer chemotherapy nurses and other health care personnel by use of the autoradiography assay. The use of this assay in human mutagenicity monitoring and the analysis of the TGr cell frequencies are discussed in terms of age effects and validation of 'elevated' frequencies by use of the clonal assay. This report then presents evidence that both assays yield similar TGr cell frequencies in two groups of 'normal adults'. The mean variant frequency (+/- S.D.) for 82 autoradiographic assays was 8.7 (+/- 6.1) X 10(-6), while the mean mutant frequency (+/- S.D.) for 115 clonal assays was 6.5 (+/- 4.8) X 10(-6). In addition, concurrent autoradiographic and clonal assays on 33 individuals yielded mean values (+/- S.D.) of 8.4 (+/- 8.5) X 10(-6) and 10.5 (+/- 6.3) X 10(-6), respectively.

Bronchogenic cancer, metastases, and aging

Previously reported large autopsy series have indicated that elderly patients who die of cancer are less likely to have metastatic disease than their younger counterparts. This observation could be explained if survival were shorter in the elderly population and patients died with smaller tumor burdens. The authors analyzed Medical Center Hospital of Vermont (MCHV) Tumor Registry data on primary lung cancer with respect to age. As in the reported autopsy series, at the time of diagnosis elderly patients were less likely to have metastatic disease. Further analysis was undertaken of the patients from this series who died and were autopsied at MCHV. Although the total numbers were small, survival was not shorter in the advanced age groups. The authors suggest that elderly patients have slower tumor growth and less metastatic disease, not because of earlier diagnosis and shorter survival, but because of senescent host factors that impede aggressive tumor growth and spread.