The Impact of Video-Based Microinterventions on Attitudes Toward Mental Health and Help Seeking in Youth: Web-Based Randomized Controlled Trial

BACKGROUND

Mental health (MH) problems in youth are prevalent, burdening, and frequently persistent. Despite the existence of effective treatment, the uptake of professional help is low, particularly due to attitudinal barriers.

OBJECTIVE

This study evaluated the effectiveness and acceptability of 2 video-based microinterventions aimed at reducing barriers to MH treatment and increasing the likelihood of seeking professional help in young people.

METHODS

This study was entirely web based and open access. The interventions addressed 5 MH problems: generalized anxiety disorder, depression, bulimia, nonsuicidal self-injury, and problematic alcohol use. Intervention 1 aimed to destigmatize and improve MH literacy, whereas intervention 2 aimed to induce positive outcome expectancies regarding professional help seeking. Of the 2435 participants who commenced the study, a final sample of 1394 (57.25%) participants aged 14 to 29 years with complete data and sufficient durations of stay on the video pages were randomized in a fully automated manner to 1 of the 5 MH problems and 1 of 3 conditions (control, intervention 1, and intervention 2) in a permuted block design. After the presentation of a video vignette, no further videos were shown to the control group, whereas a second, short intervention video was presented to the intervention 1 and 2 groups. Intervention effects on self-reported potential professional help seeking (primary outcome), stigma, and attitudes toward help seeking were examined using analyses of covariance across and within the 5 MH problems. Furthermore, we assessed video acceptability.

RESULTS

No significant group effects on potential professional help seeking were found in the total sample (F2,1385=0.99; P=.37). However, the groups differed significantly with regard to stigma outcomes and the likelihood of seeking informal help (F2,1385=3.75; P=.02). Furthermore, separate analyses indicated substantial differences in intervention effects among the 5 MH problems.

CONCLUSIONS

Interventions to promote help seeking for MH problems may require disorder-specific approaches. The study results can inform future research and public health campaigns addressing adolescents and young adults.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023110; https://drks.de/search/de/trial/DRKS00023110.

International and domestic university students' mental health over the course of the COVID-19 pandemic in Germany: Comparison between 2020, 2021, and 2022

BACKGROUND

The COVID-19 pandemic affected university students' mental health worldwide. International students were presenting high levels of stress, anxiety, and depressive symptoms before the pandemic. This study aimed to investigate (i) differences between various timepoints of the COVID-19 pandemic (2020, 2021, and 2022) in mental health outcomes and social and emotional aspects in domestic and international students, separately, (ii) differences between international and domestic students between the three timepoints on mental health outcomes and social and emotional aspects, and (iii) possible moderation effects of timepoints on mental health outcomes and social and emotional aspects of domestic and international students.

MATERIAL AND METHODS

Data from three cross-sectional anonymous online surveys conducted in German universities were analyzed and compared. Data were collected in 2020, 2021, and 2022, respectively, with a total N = 14,498. Depressive symptoms, hazardous alcohol use, social support, self-efficacy, resilience, perceived stress, and loneliness were assessed through standardized self-report instruments. Differences between domestic and international students in mental health outcomes, and social and emotional aspects across three timepoints were assessed with one-way and two-way ANCOVAs.

RESULTS

Regardless of the timepoint, international students presented more depressive symptoms and perceived stress, lower perceived social support and resilience, but higher levels of self-efficacy and less alcohol consumption compared to domestic students. A significant interaction effect between timepoint and student status emerged only for loneliness.

CONCLUSIONS

International students generally presented poorer mental health outcomes than domestic students. Mental health care and prevention such as low-threshold, online counseling should address university students, especially international students.

Linguistic Variables and Gender Differences Within a Messenger-Based Psychosocial Chat Counseling Service for Children and Adolescents: Cross-Sectional Study

BACKGROUND

Text messaging is widely used by young people for communicating and seeking mental health support through chat-based helplines. However, written communication lacks nonverbal cues, and language usage is an important source of information about a person's mental health state and is known to be a marker for psychopathology.

OBJECTIVE

The aim of the study was to investigate language usage, and its gender differences and associations with the presence of psychiatric symptoms within a chat counseling service for adolescents and young adults.

METHODS

For this study, the anonymized chat content of a German messenger-based psychosocial chat counseling service for children and adolescents ("krisenchat") between May 2020 and July 2021 was analyzed. In total, 661,131 messages from 6962 users were evaluated using Linguistic Inquiry and Word Count, considering the following linguistic variables: first-person singular and plural pronouns, negations, positive and negative emotion words, insight words, and causation words. Descriptive analyses were performed, and gender differences of those variables were evaluated. Finally, a binary logistic regression analysis examined the predictive value of linguistic variables on the presence of psychiatric symptoms.

RESULTS

Across all analyzed chats, first-person singular pronouns were used most frequently (965,542/8,328,309, 11.6%), followed by positive emotion words (408,087/8,328,309, 4.9%), insight words (341,460/8,328,309, 4.1%), negations (316,475/8,328,309, 3.8%), negative emotion words (266,505/8,328,309, 3.2%), causation words (241,520/8,328,309, 2.9%), and first-person plural pronouns (499,698/8,328,309, 0.6%). Female users and users identifying as diverse used significantly more first-person singular pronouns and insight words than male users (both P<.001). Negations were significantly more used by female users than male users or users identifying as diverse (P=.007). Similar findings were noted for negative emotion words (P=.01). The regression model of predicting psychiatric symptoms by linguistic variables was significant and indicated that increased use of first-person singular pronouns (odds ratio [OR] 1.05), negations (OR 1.11), and negative emotion words (OR 1.15) was positively associated with the presence of psychiatric symptoms, whereas increased use of first-person plural pronouns (OR 0.39) and causation words (OR 0.90) was negatively associated with the presence of psychiatric symptoms. Suicidality, self-harm, and depression showed the most significant correlations with linguistic variables.

CONCLUSIONS

This study highlights the importance of examining linguistic features in chat counseling contexts. By integrating psycholinguistic findings into counseling practice, counselors may better understand users' psychological processes and provide more targeted support. For instance, certain linguistic features, such as high use of first-person singular pronouns, negations, or negative emotion words, may indicate the presence of psychiatric symptoms, particularly among female users and users identifying as diverse. Further research is needed to provide an in-depth look into language processes within chat counseling services.

Reasons for non-participation of children and adolescents in a large-scale school-based mental health project

Background

Non-participation in mental health studies is an under-explored but very important topic. Investigating reasons for non-participation holds promise for the planning of future study designs and recruitment strategies. This study aimed at investigating reasons for children and adolescents (C&A) not participating in a school-based mental health research project.

Methods

Data collection took place within the school-based recruitment of a large-scale multi-site project ("ProHEAD-Promoting Help-seeking using E-technology for Adolescents") in Germany. Participants were N = 534 C&A aged ≥ 12 years attending secondary schools. The present cross-sectional study analyzed anonymous survey data of C&A who themselves or whose parents, respectively, did not provide written consent to participate in the mental health research project. The questionnaire consisted of 14 items covering potential reasons for non-participation, and four free text fields. Besides descriptive statistics, free text field answers were analyzed using qualitative content analysis.

Results

Students indicated an average of M = 2.94 (SD = 1.75) reasons for their non-participation in the project. In the descriptive analysis of indicated items, the three most frequently reported reasons for non-participation included students reporting to not be concerned by the topic "mental health" (n = 290, 54.3%), not having returned the consent form to the teacher (n = 175, 32.8%), and not having time for participation (n = 149, 27.9%). In the qualitative content analysis, the most frequently assigned categories were organizational reasons (n = 216, 57.1%), general disinterest in study participation (n = 139, 36.8%), and personal attitudes toward the topic "mental health" (n = 84, 22.2%), such as not being concerned with the topic "mental health" (n = 23, 6.1%) or being too concerned with the topic "mental health" (n = 16, 4.2%).

Conclusion

The study provides unique insights into reasons for C&A and their caregivers not participating in a large federally funded mental health research project. The results suggest that in order to increase participation rates, stigma should be reduced, parents as well as teachers should be involved where possible, and the use of incentives might be helpful. The study highlights the importance of assessing reasons for non-participation, especially in online intervention studies on mental health.

Acceptability, feasibility, and user satisfaction of a virtual reality relaxation intervention in a psychiatric outpatient setting during the COVID-19 pandemic

Background

The COVID-19 pandemic was particularly difficult for individuals with mental disorders. Due to governmental restrictions, face-to-face offers for psychiatric outpatients like therapies, psychoeducational groups or relaxation courses were limited. Virtual reality (VR) might be a new possibility to support these patients by providing them with a home-based relaxation tool.

Objective

The aim of this study was to evaluate the acceptability, feasibility, and user satisfaction of a supportive therapy-accompanying, relaxation VR intervention in psychiatric outpatients during the COVID-19 pandemic in Germany.

Methods

The four-weeks VR intervention consisted of regular watching of relaxing videos in the participants' home environment. Sociodemographics, feasibility (frequency of use, user-friendliness), satisfaction (Client Satisfaction Questionnaire-8), depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), and credibility and expectancy (Credibility Expectancy Questionnaire-8) were measured in an intention-to-treat (ITT) analysis and a per-protocol (PP) analysis of completers.

Results

In total, N = 40 patients participated in the study. Most of the participants in the ITT analysis (n = 30, 75.0%) used the VR device three or 4 weeks. A majority of the N = 29 completers (PP: n = 18, 62.1%) used it all 4 weeks. Most participants used the device two or more times a week (ITT: n = 30, 83.3%; PP: n = 26, 89.7%) and described the user-friendliness as rather or very easy (ITT: n = 33, 91.7%; PP: n = 26, 89.7%). User satisfaction was high (ITT: 19.42, SD = 4.08; PP: M = 20.00, SD = 4.19) and did not correlate with participants' sex or age (all p < 0.05). Depressive symptoms and psychological quality of life improved significantly from pre-to post-intervention (ITT and PP, all p < 0.05). Higher pre-intervention credibility significantly correlated with a better outcome of satisfaction (ITT and PP), depressive symptoms, physical, psychological, and social quality of life (PP; all p < 0.05).

Conclusion

A supportive therapy-accompanying VR relaxation intervention is feasible and acceptable in a psychiatric outpatient setting. Due to the high satisfaction and user-friendliness, VR can be an easy to implement relaxation tool to support psychiatric outpatients.

Clinical trial registration

https://clinicaltrials.gov/, DRKS00027911.

Differences in Help-Seeking Behavior among University Students during the COVID-19 Pandemic Depending on Mental Health Status: Results from a Cross-Sectional Survey

BACKGROUND

Current evidence suggests that a significant proportion of university students are affected by mental disorders and suicidal ideation. Despite this, a treatment gap exists. Therefore, the present study assessed students' knowledge and past use of on- and off-campus mental health services and help-seeking intentions. Furthermore, resilience was investigated as a potential barrier to help-seeking behavior.

METHODS

Data were collected between April and May 2022 from N = 5510 students from Saxony, Germany. To compare dependent variables, subgroups were computed according to students' mental health status. Variables were assessed using standardized questionnaires. Chi-square tests were used for comparisons between groups. Multiple regression models were used to investigate the influence of resilience on help-seeking behavior.

RESULTS

Between 34 and 38% (depending on the subgroup) of participants indicated that they were not aware of their universities' psychosocial counseling services. Furthermore, between 17 and 19% of participants indicated that they were not willing to seek help from professional mental health services. Finally, the previously found negative effect of resilience on help-seeking behavior was confirmed.

CONCLUSION

The results showed a lack of awareness regarding universities' mental health services and a treatment gap among university students. Universities and healthcare providers need to educate students about mental health services and how to access them. Further research is needed to elucidate the differential impact of resilience on mental health and help-seeking.

Acceptability and Feasibility of Online Support Groups for Mental Health Promotion in Brazilian Graduate Students During the COVID-19 Pandemic: Longitudinal Observational Study

BACKGROUND

The outbreak of the COVID-19 pandemic in 2020 aggravated already existing difficulties and added new challenges for students. Owing to the gap between needed and available psychological services, group interventions may offer a helpful strategy for student mental health promotion.

OBJECTIVE

This study aimed to investigate the acceptability and feasibility of a 4-week online support group program designed for mental health promotion tailored to graduate students at a Brazilian public university in the context of the COVID-19 pandemic (May 2022 to June 2022).

METHODS

Participants in the program took part in online support groups based on a pilot group facilitated by a trained clinical psychologist. Self-administered, standardized web-based questionnaires were assessed at the baseline (T0; before the intervention), postintervention (T2), and follow-up (T3; after 4-6 weeks) time points. We measured sociodemographic variables, treatment credibility and expectancy (Credibility and Expectancy Questionnaire), satisfaction (Client Satisfaction Questionnaire), negative effects of the intervention (Negative Effects Questionnaire), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and participants' quality of life (abbreviated World Health Organization Quality of Life assessment). A 9-answer option questionnaire and open-ended questions also assessed the group's perceived positive and negative outcomes.

RESULTS

The total sample comprised 32 participants. Most (23/32, 72%) were doctoral students. Credibility and expectancy scores were high. Participants' satisfaction (Client Satisfaction Questionnaire) with the program was high at the postintervention (T2) and follow-up (T3) evaluations (T2: mean 28.66, SD 3.02; T3: mean 27.91, SD 3.02). Most participants reported that they could learn from other participants' experiences (T2: 29/32, 91%; T3: 27/32, 84%) and felt encouraged to take better care of themselves (T2: 22/32, 69%; T3: 24/32, 75%). None of the participants reported that they had no benefits from the program. The PHQ-9 scores showed mild to moderate depressive symptoms (mean 9.59, SD 6.34), whereas the answers of 9% (3/32) of the participants to the PHQ-9 item 9 indicated suicidality at baseline (T0). Finally, the 4 domains of quality of life (physical: P=.01; psychological: P=.004; social: P=.02; and environmental: P<.001) showed a slight and statistically significant improvement at the postintervention evaluation (T0: mean 57.03, SD 15.39 to 59.64, SD 17.21; T2: mean 64.32, SD 11.97 to 68.75, SD 8.87).

CONCLUSIONS

Online support groups for the mental health promotion of graduate students are feasible and can be especially useful for universities with students allocated to different cities. They are also satisfactory and may positively influence participants' quality of life. Therefore, they can be considered a helpful mental health promotion strategy in the educational context. Further studies could evaluate these (or similar) programs under nonpandemic circumstances.

Who are frequent chatters? Characterization of frequent users in a 24/7 messenger-based psychological chat counseling service for children and adolescents

Background

Online helplines have shown a high acceptance, feasibility, and usability, especially with young people. Helplines usually aim to provide one-time crisis intervention; however, there are users who frequently use such services, tying a disproportionately large proportion of service capacities. To date, there is no research on the characterization of frequent users of online helplines. Therefore, the aim of the present study is to characterize frequent chatters in a chat-based counseling context.

Methods

This cross-sectional study retrospectively analyzed anonymous data of users who approached the German messenger-based psychological chat counseling service krisenchat between May 2020 and July 2021 (N = 6657), with a focus on frequent users - the "frequent chatters". Frequent chatters were defined as those who received an above average (M + 2 ∗ SD) amount of messages from counselors over a period of one week and had at least 7 days of contact with the service over the entire data collection period. Chi-square-tests and Mann-Whitney-U tests were conducted to identify differences between frequent users and the population of all users.

Results

In total, n = 99 (1.5 %) users met the definition for frequent chatters and accounted for roughly a tenth (9.85 %) of all chats of the service. The mean frequent chatter was 17 years old (M = 17.29, SD = 3.56), female (n = 78, 82.1 %), and approached the service in the late afternoon (M = 5:00 pm, SD = 5:25 h). Compared to the general user population, frequent chatters reported significantly more severe concerns to counselors, of which 81.8 % included psychiatric symptoms, such as suicidality (43.4 %) and non-suicidal self-injury (41.4 %). In addition, frequent chatters were significantly more likely to contact krisenchat alongside the use of other professional help services. Further, frequent chatters wrote significantly longer and more messages during the counseling process and within a session than the general user population of krisenchat. Compared to the general user population, frequent chatters did not differ in their satisfaction with the service.

Conclusion

Frequent users are known from telephone helplines and are also represented in a chat-based context. Compared to the general user population, they are more likely to report serious mental health conditions and half of them currently receive professional help, suggesting a high need for social support. In light of the increasing development of chat-based helplines, there is a need for further research on frequent chatters to develop tailored counseling strategies for their needs and to analyze options for an optimized service provision.

Study registration

DRKS00026671.

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 a Messenger-Based Psychosocial Chat Counseling Service on Further Help-Seeking Among Children and Young Adults: Longitudinal Study

BACKGROUND

Mental crises have high prevalences in adolescence. Early interventions appear to be highly important to diminish the risk of the deterioration, recurrence, or chronification of symptoms. In recent years, various providers have started offering live chat support in psychological crises. The messenger-based psychological counseling service krisenchat aims to support young people in crises and, if necessary, provide a recommendation for a referral to the health care system or to seek further help from a trusted adult person.

OBJECTIVE

This study aimed to investigate the impact of using the counseling service of krisenchat on the further help-seeking behavior of young people, and to identify associated factors of further help-seeking.

METHODS

This longitudinal study analyzed anonymous data from 247 individuals who used krisenchat between October 2021 and March 2022, and received a recommendation for further help-seeking. An online survey directly after the chat assessed the perceived helpfulness of the chat and well-being after the chat. After 4 weeks, further help-seeking, facilitators and barriers to help-seeking, and self-efficacy were assessed in an online follow-up survey.

RESULTS

The most frequently recommended services or persons to seek further help from included a psychotherapist or social psychiatric service (75/225, 33.3%), a school psychologist or school social worker (52/225, 23.1%), and the user's parents (45/225, 20.0%). Of the 247 users, 120 (48.6%) indicated that they contacted the recommended service or person, and of these, 87 (72.5%) stated that they already had an appointment (or talk) with the respective service or person or that an appointment (or talk) was scheduled. The most frequently reported facilitators for further help-seeking were mental health literacy (54/120, 45.0%), improvement of self-efficacy (55/120, 45.8%), and symptom recognition (40/120, 33.3%). In users not displaying further help-seeking behavior, the most frequent barriers included stigmatization (60/127, 47.2%), lack of mental health literacy (59/127, 46.5%), need for self-reliance and autonomy (53/127, 41.7%), and negative family beliefs regarding help services (53/127, 41.7%). Subgroup comparisons indicated significantly higher levels of self-efficacy in users displaying further help-seeking behavior than in those not displaying further help-seeking behavior. Both subgroups did not differ in gender, age, recommended service or person, chat topics, perceived helpfulness, and well-being.

CONCLUSIONS

The findings of this study indicate that children and young adults receiving counseling on krisenchat benefit in terms of seeking further help. Further help-seeking seems to be associated with higher levels of self-efficacy.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien DRKS00026671; https://tinyurl.com/4fm5xe68.

How are Brazilian university students coping with the COVID-19 pandemic? Results of an online survey on psychosocial well-being, perceived burdens, and attitudes toward social distancing and vaccination

BACKGROUND

The COVID-19 pandemic caused significant disruption to education systems worldwide, increasing pre-existing concerns regarding university students' mental health. Brazil was among the countries most affected by COVID-19 cases and deaths and was considered a pandemic epicenter. This study aimed to investigate Brazilian university students' mental health status and perceived burdens during the COVID-19 pandemic.

MATERIAL AND METHODS

From November 2021 to March 2022, a cross-sectional and anonymous online survey was conducted among students of a Brazilian federal university. Mental health status (depressive symptoms, alcohol and drug consumption) and social and emotional aspects in the pandemic context (social support, perceived stress, loneliness, resilience, and self-efficacy) were assessed with standardized measures. Students' attitudes toward the COVID-19 pandemic and vaccination and perceived burdens of the pandemic were also investigated.

RESULTS

A total of N = 2,437 students completed the online survey. The PHQ-9 mean sum score was 12.85 (SD = 7.40), while n = 1,488 (61.10%) participants reported a sum score of 10 or more, indicating clinically relevant depressive symptoms. Further, n = 808 (33.1%) of the total sample reported suicidal thoughts. Levels of depressive symptoms, perceived stress, and loneliness were higher among undergraduate/bachelor students than doctoral students. Almost all participants (97.3%) reported being fully vaccinated against COVID-19. Multiple regression analyses showed that being single, having an income decreased during the pandemic, having a previous mental illness, having a chronic somatic condition, not finding positive aspects in the pandemic, lower self-efficacy, lower social support, lower resilience, and higher experienced loneliness were significantly associated with higher levels of depression.

CONCLUSIONS

The study showed high levels of depressive symptoms and suicidal ideation among Federal University of Parana students. Therefore, health care providers and universities need to recognize and address mental health issues; psychosocial policies must be enhanced to mitigate the impact of the pandemic on students' mental health and wellbeing.

Help-seeking attitudes and behaviours for mental health problems in adolescents before and during the first COVID-19 school closures in Germany

AIM

Comparing measures of psychological wellbeing and help-seeking in youths before and within the first school closures due to the coronavirus disease 2019 (COVID-19) pandemic enables a better understanding of the effects the pandemic has for those seeking professional help for mental health problems.

METHODS

Data were obtained from the Germany-based ProHEAD school study. Pre-lockdown and lockdown samples (n = 648) were compared regarding pupils' psychological wellbeing, help-seeking attitudes and help-seeking behaviour.

RESULTS

Participants from the lockdown sample showed greater positive attitudes towards seeking professional help, whereas psychological wellbeing and help-seeking behaviour remained stable.

CONCLUSIONS

Possible explanations may include an increased public discourse on mental health or self-selection bias for participation during lockdown.

Two years COVID-19 pandemic: Development of university students' mental health 2020-2022

Background

The literature indicates a negative impact on the mental health of university students during the COVID-19 pandemic. It remains unclear if this negative impact persists even after lockdown measures are lifted. The current study therefore investigates the mental health status of students by drawing on two previous studies the present study seeks to investigate differences in the mental health status across three time points.

Methods

A cross-sectional, anonymous online survey among students of six universities was conducted between April and May 2022 (N = 5,510). Symptoms of depression, anxiety, hazardous alcohol use and eating disorders as well as social and emotional variables were assessed utilizing standardized instruments. Risk- and protective factors for severity of depressive and anxiety symptoms were investigated using multiple regression models. Differences in e.g., symptoms of depression across three time points were assessed with one-way analysis of variance.

Results

More than one third of students exhibited clinically relevant symptoms of depression (35.5%), hazardous alcohol use (33.0-35.5% depending on gender) or anxiety disorder (31.1%). Taken together, almost two out of three (61.4%) students reported clinically relevant symptoms in at least one of the aforementioned symptom patterns, while almost one fifth of students reported suicidal ideation or thoughts of self-harm (19.6%). Higher perceived stress and loneliness significantly predicted higher levels of depressive symptoms, while resilience and social support were identified as protective factors. Compared to 2020 and 2021, levels of depressive symptoms were significantly reduced in 2022, levels of hazardous alcohol consumption showed a small but significant increase from 2021 to 2022. Worryingly, prevalence of suicidal ideation was the highest yet, being significantly higher than in 2020 (14.5%) and 2021 (16.5%).

Conclusion

These results confirm previous results that the pandemic had and still has a negative impact on the mental health of university students. The present study broadens this view by the fact that some areas seem to recover quicker, while others seem to increase worryingly. Especially the persistent rise in suicidal ideation from 2020 to 2021 and to 2022, a constant reduction in reported social support and associated perceived loneliness is concerning. The claim for low-threshold and accessible mental health support for university students remains the same as in the beginning of the pandemic.

Attitudes toward the pandemic and COVID-19 vaccination intention among German university students and the general population: Results from two cross-sectional surveys

Background

The COVID-19 pandemic has had an impact on nearly all people. Vaccines provide an effective tool to combat the pandemic, however, vaccination hesitancy remains an issue. This study aims to investigate (a) students' attitudes toward the pandemic, (b) potential differences in attitudes between university students and the general population, and (c) to examine predictors of vaccination intention in both samples.

Methods

In this cross-sectional study data from two research projects were analyzed and compared. First, attitudes toward the COVID-19 pandemic in German university students were assessed within a cross-sectional anonymous online survey (March-April 2021, N = 5,639) and analyzed quantitatively and also qualitatively (free text field answers examined positive and negative aspects of the pandemic). Second, data from a cross-sectional survey within the COVID-19 Snapshot Monitoring project (COSMO; 29^th wave of data collection, December 2020, N = 1,387) in the German general population was analyzed. Both samples, were compared in sharedly used variables, regarding attitudes toward the pandemic and vaccination intention, and factors associated with vaccination (logistic regression analyses).

Results

In comparison to the general population, university students were significantly more likely to report being worried about/thinking about the coronavirus and to perceive the coronavirus as overrepresented in the media (all p < 0.001). University students reported a more supportive attitude toward vaccinations in general (students: M = 4.57, SD = 0.85; general population: M = 3.92, SD = 1.27) and a significantly higher vaccination intention (students: n = 4,438, 78.7%; general population: n = 635, 47.7%) than the general population (p < 0.001). Regression analyses revealed that in university students, vaccination intention was significantly predicted by not having children, a supporting attitude toward vaccinations in general, the belief that the coronavirus is overrepresented in the media, and less thinking about/worrying about the coronavirus (all p < 0.05). In the general population, vaccination intention was significantly associated with male gender, higher age, not having children, a supporting attitude toward vaccinations in general, and the belief that the coronavirus is overrepresented in the media (p < 0.05). The qualitative analysis among university students revealed that the most frequently stated positive aspect of the pandemic was to be more flexible due to digitalization (n = 1,301 statements, 22.2%) and the most frequently stated negative aspect was restriction in social life (n = 3,572 statements, 24.2%).

Conclusion

The results indicate differences in the attitudes toward the pandemic between university students and the general population. In addition, differences regarding factors associated with vaccination intention were found in both samples. These results could be important to be considered when designing and targeting vaccination campaigns aiming at informing different population or age groups.

Study registration

DRKS00022424.

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.

Stable through the COVID-19 pandemic: Results from a longitudinal telephone interview study in psychiatric outpatients

BACKGROUND

The COVID-19 pandemic was associated with far-reaching changes all over the world. Health care systems were and are also affected. Little is known about the impact of these changes and the duration of the pandemic on people with mental disorders. The aim of this longitudinal follow-up study was to investigate the mental health status, medical care provision, and attitudes towards the pandemic of these people at the end of the second pandemic lockdown in Germany in 2021, and to compare these findings with the results of 2020.

METHODS

People with mental disorders currently receiving treatment in the psychiatric outpatient department of the University Hospital Leipzig, Germany, were asked about depressive symptoms (PHQ-9), self-reported medical care provision, attitudes and social and emotional aspects of the pandemic (social support [ESSI], perceived stress [PSS-4], loneliness [UCLA-3-LS], and resilience [BRS]) using structured telephone interviews.

RESULTS

In total, N = 75 participants who had already participated in the first survey in 2020 took part in the follow-up telephone interviews. The most frequent clinician-rated diagnoses were attention deficit disorder/attention deficit hyperactivity disorder (n = 21; 28.0%) and obsessive-compulsive disorder (n = 16; 21.3%). In comparison to 2020, a significantly higher proportion of participants reported no problems in receiving medical care provision. Compared to the previous year, the resilience of the participants had significantly decreased. Depressive symptoms, social support, perceived stress, and loneliness remained stable. Significantly more participants felt restricted by the pandemic-related government measures in 2021 than in 2020.

CONCLUSIONS

This study highlights the importance for continued efforts to maintain stable medical care provision for people with mental disorders during the COVID-19 pandemic, as except for a decrease in resilience, mental health status remained stable. Nonetheless there is still a need for continued treatment to stabilise and improve this status.

Moderators of pre-post changes in school-based mental health promotion: Psychological stress symptom decrease for adolescents with mental health problems, knowledge increase for all

Background

School-based mental health promotion aims to strengthen mental health and reduce stress. Results on the effectiveness of such programs are heterogeneous. This study realized a school-based mental health promotion program (StresSOS) for all students and aimed to identify moderators (mental health status, gender, grade level) of pre- to post-changes in stress symptoms and knowledge.

Methods

Participants were N = 510 adolescents (from 29 classes; 46.7% female) aged 12-18 years (M = 13.88, SD = 1.00; grade levels 7-10). They were without mental health problems (65.9%), at risk for mental health problems (21.6%), or with mental health problems (12.5%) and participated in a 90 min per week face-to-face training with 8 sessions in class at school. Demographic variables, mental health status, stress symptoms, and knowledge about stress and mental health were collected at baseline. Program acceptance, stress symptoms, and knowledge were collected post-intervention. Multilevel mixed effects models were conducted with the fixed effects time (within factor), mental health status, gender, and grade level (between factors). Random effects for students within classes were included.

Results

In the pre-post comparison, mental health status moderated the changes on psychological stress symptoms (p < 0.05). In adolescents with mental health problems the largest reduction in stress symptoms was observed between pre- and post-assessment. Gender and grade level were less relevant. For all adolescents knowledge gains were revealed (p < 0.001). Program acceptance was moderated by mental health status and grade level (p < 0.01). Mentally healthy adolescents and within the group of adolescents at-risk or with mental health problems, especially younger students (7th/8th grade), rated program acceptance higher.

Conclusion

Psychological stress symptoms decreased among adolescents with mental health problems and not among adolescents at risk for or without mental health problems. Mental health-related knowledge increased for all adolescents. The results add to knowledge on school-based mental health intervention research and practice. Its implications for different prevention strategies (universal, selective or a combination of both) are discussed.

["iFightDepression" in inpatient treatment : Evaluation of a web-based, therapist-guided self-management program on a specialized ward for affective disorders]

BACKGROUND

E‑mental health mainly plays a role in the outpatient treatment of patients with depressive disorders. The goal of this study was to implement and evaluate the web-based, therapist-guided self-management tool "iFightDepression" (iFD) to clarify if there is a benefit for inpatient use.

MATERIAL AND METHODS

In this study 78 inpatients with affective disorders (ICD-10 F32.0‑3, F33.0-3) or dysthymia (F34) were recruited. The intervention duration with the iFD tool went from admission until discharge, therapeutic support was granted by the ward staff. Symptom severity, intervention expectations and experience with therapy were processed in an online questionnaire before the intervention (T0) while intervention satisfaction was captured after the intervention shortly before discharge (T1) in a paper-pencil questionnaire.

RESULTS

Out of 78 participating inpatients 42 used the iFD tool at least once. Moderate to high levels of expectation regarding the iFD tool and mildly above-average level of satisfaction after the intervention were observed. Of the active users 67% indicated they would continue to use the iFD tool after discharge. The main reasons for not using the iFD tool were short duration of stay, severity of disease and lack of digital literacy.

CONCLUSION

An implementation of the iFD tool is feasible on principle. Active users gave positive feedback concerning the intervention and most participants claimed to continue using the iFD tool after discharge; however, low usage rates among study participants (42/78, 54%) showed barriers of implementation that have to be addressed and underline the importance of adaptations regarding the use of the intervention in a clinical setting.

Acceptability and feasibility of a messenger-based psychological chat counselling service for children and young adults ("krisenchat"): A cross-sectional study

BACKGROUND

Adolescence represents a vulnerable period to experience personal crises or mental health problems. However, many concerns stay unnoticed due to the hesitance of young people to seek help and the unavailability and inaccessibility of appropriate help services. Contemporary interventions have been developed incorporating with target group specific needs and preferred modes of communication. krisenchat (German for "crisis chat") is a German low-threshold chat-based psychosocial crisis counselling service that is available around-the-clock. Despite the growing number of online support services, there is a dearth of research regarding the acceptability, usability, and feasibility.

METHODS

The present cross-sectional study analyzed retrospective anonymous data on sociodemographic variables, utilization behavior, and user satisfaction of all krisenchat users between May 2020 and July 2021. Predictors of user satisfaction were identified using exploratory multiple regression analysis. Subgroup analyses were conducted using chi-square-tests to identify differences in user satisfaction.

RESULTS

Data of N = 6962 users was included in the analysis. More than 50% of those reported not having contacted the professional health care system before. The mean user of krisenchat was 17 years old (M = 16.6, SD = 3.5), female (female: 83.4%, male: 14.7%, diverse: 1.8%), and first approached the service at 4 PM (M = 4:03 PM, SD = 5:44 h). More than 60% of the users contacted the service between 4 PM and 12 AM, 10% even between 12 AM and 8 AM. The most frequent chat topics were concerns regarding psychiatric symptoms (60.1%), psychosocial (34.0%) or emotional distress (30.2%). The majority of the users (64.7%) reported high levels of satisfaction and 88.3% a high likelihood (60% or more) of recommending krisenchat to others. Also, the results indicate that the number of messages and their respective length differed between users and counsellors, with users writing several, but shorter messages and counsellors replying with fewer, but longer messages.

CONCLUSION

The results of the present study imply a high acceptability and feasibility of krisenchat. Overall, there is a high need for a 24/7 messenger-based chat counselling service in crises for children and young adults. Currently, there is no other online service for youth that is available after 7 PM or at weekends, which indicates the great importance of krisenchat and its function to bridge a current gap in the mental health care system. A need for further research emerges e.g., for subgroup differences regarding utilization patterns and also for further insights regarding help-seeking behavior via social media in youth.

STUDY REGISTRATION

DRKS00026671.

Eating attitudes and depressive symptoms in a LGBTIQ sample in Turkey

BACKGROUND

Lesbian, gay, bisexual, transgender, intersexual and queer (LGBTIQ) individuals are often stigmatized due to their minority status. Sexual-minority stress is often discussed as a risk factor for the increased mental health problems reported in this population.

OBJECTIVE

The current study (1) investigated eating attitudes and depressive symptoms in a sexual minority sample from Turkey who identify themselves as LGBTIQ and (2) explored the role of sexual minority stressors beyond the potential predictors of eating attitudes and depressive symptoms in this population.

METHODS

Recruitment was supported and streamlined by several Turkish NGOs and LGBTIQ community networks. Sociodemographic measures, eating attitudes, depressive symptoms, sexual minority stressors (e.g., heterosexist experiences, internalized homophobia), and the potential predictors of eating attitudes and depressive symptoms were assessed with an anonymous online survey between February 2022 and June 2022. The sample consisted of 440 participants. The mean age was 31.92 (SD = 11.82). The majority of the participants reported their current gender identity as male (64.3%; n = 440) and their sexual orientation as attracted to men (62.8%; n = 439). For 79.7% of the participants, the assigned sex at birth was man (n = 439).

RESULTS

Two separate three-stage multiple hierarchical regression analyses were conducted, controlling for sociodemographic characteristics and the risk and protective factors of eating attitudes and depressive symptoms. Disturbed eating attitudes were predicted by assigned female sex at birth, higher scores for depression, social isolation, and the total number of heterosexist experiences, and lower distress related to heterosexist experiences. Depressive symptoms were predicted by assigned female sex at birth, lesbian sexual orientation, disturbance in eating attitudes, increases in generalized anxiety, and distress related to daily heterosexist experiences.

CONCLUSION

The current study demonstrated the significant role of sexual minority stressors in the prediction of disturbed eating attitudes and depressive symptomatology beyond the general psychosocial vulnerability factors. These findings emphasize the need for developing strategies to reduce prejudicial attitudes at the societal level and to enhance the skills of LGBTIQ individuals in coping with sexual minority stressors in Turkey.

Suicidal Ideation Among Children and Young Adults in a 24/7 Messenger-Based Psychological Chat Counseling Service

BACKGROUND

Suicidality in children and young adults is a pervasive problem: approximately 40% of respondents in epidemiological surveys in German schools reported suicidal ideation, while up to 9% reported a suicide attempt in the past. While there is compelling evidence for the effectiveness of telephone-based hotline services, an increasing preference of adolescents for messenger-based counseling services can be observed. Therefore, the present study aims to investigate the utilization behavior and user satisfaction of users contacting a German messenger-based chat counseling service ("krisenchat") regarding suicidal ideation.

METHODS

The present cross-sectional study analyzed retrospective anonymous data on sociodemographic variables, utilization behavior, and user satisfaction of krisenchat users who used the service between May 2020 and July 2021. Chi-square-tests were used to identify associations of sociodemographic characteristics and utilization behavior with suicidal ideation. Mann-Whitney-U-tests were used to compare the user satisfaction and the recommendation-to-others-rate between suicidal and non-suicidal krisenchat-users.

RESULTS

In total, chat data of N = 11,031 users were collected. Of the n = 6,962 users included in the final analysis, n = 1,444 (20.7%) contacted krisenchat because of suicidal ideation. The average user experiencing suicidal ideation was 17 years old, female and currently not receiving other treatment. Further, suicidal ideation was significantly and positively associated with age and non-suicidal self-injury. Regarding utilization patterns, there were significant positive associations between suicidal ideation and counseling session count, mean amount of messages sent, and mean amount of words used per message by the user. User satisfaction was high, with 64.7% (n = 413) of users that answered the feedback survey and experiencing suicidal ideation rating the help they received as at least "good" and a recommendation rate of 89.6% (n = 571). Most importantly, no differences were found between users reporting suicidal ideation and those that do not regarding satisfaction and the probability of recommending the service.

CONCLUSION

Results imply satisfaction with the counseling service among users with suicidal ideation. Nevertheless, there is a need for further research into messenger-based counseling services regarding the prevention of suicidal behavior in children, youths, and young adults. Longitudinal studies are especially needed to assess the effectiveness of messenger-based interventions.

STUDY REGISTRATION

DRKS00026671.

More Depressive Symptoms, Alcohol and Drug Consumption: Increase in Mental Health Symptoms Among University Students After One Year of the COVID-19 Pandemic

Background: As the majority of studies examining mental health during the pandemic are cross-sectional, little is known about the changes in mental health during the pandemic, especially in university students. Most studies indicate a worsening of mental health conditions. This study aimed to evaluate the mental health status of German university students during the third wave of the pandemic in 2021 and to compare the results to a sample of a congruent cross-sectional study from 2020. Methods: Two cross-sectional and anonymous online surveys among university students were conducted (first survey: July-August 2020, N = 3,382; second survey: March-April 2021, N = 5,642). Mental health status was assessed with standardized measures (depressive symptoms, alcohol and drug consumption, and eating disorder symptoms), and social and emotional aspects of the COVID-19 pandemic were assessed. In addition to descriptive statistics and group comparisons of the two survey samples from 2020 and 2021, respectively, risk and protective factors related to mental health were analyzed. Results: There were significant differences in severities of depressive symptoms and alcohol and drug consumption between the two online surveys from 2020 and 2021. Findings suggest an increase in the severity of depressive symptoms as well as alcohol and drug consumption. Significantly more respondents reported suicidal ideation in the survey from 2021. Lower self-efficacy, less social support and lower resilience as well as higher perceived stress and more loneliness were reported by the participants of the survey from 2021 compared to 2020. Regarding factors predicting mental health symptoms, being female was a positive predictor for hazardous alcohol use and anorexia nervosa in comparison to men. Further, younger age, being diverse, higher perceived stress and loneliness were positive predictors for all mental health outcomes. Conclusion: This study reveals an increase in severities of depressive symptoms, including suicidal ideation, drug and alcohol consumption among students. Being diverse, younger age, higher perceived stress and loneliness were mutual risk factors for higher depressive and eating disorder symptoms as well as alcohol consumption. Universities and health care policy should recognize and address mental health issues of young adults during ongoing times of crisis and invest in easy-to-access interventions.

Long durations from symptom onset to diagnosis and from diagnosis to treatment in obsessive-compulsive disorder: A retrospective self-report study

BACKGROUND

Although obsessive-compulsive disorder (OCD) is one of the most common mental disorders, it takes up to 17 years for patients with OCD to receive adequate therapy. According to existing outdated literature, this study aimed to investigate the current duration between symptom onset and diagnosis and between diagnosis and the beginning of therapy separately.

METHODS

In a cross-sectional study, N = 100 patients diagnosed with OCD undergoing treatment in a psychiatric outpatient department were assessed, using self-report questionnaires on sociodemographic and clinical variables. Based on self-reported information, the durations between age at symptom onset and age at diagnosis, and between age at diagnosis and beginning of therapy were calculated. To investigate associated factors, two subgroups of patients, one with a short duration between symptom onset and diagnosis < 7 years, and another with a long duration between symptom onset and diagnosis ≥ 7 years, respectively, were compared.

RESULTS AND CONCLUSION

Patients reported first symptoms of OCD at a mean age of 18.72 years. The mean duration between age at symptom onset and age at diagnosis was 12.78 years and the mean duration between age at diagnosis and the beginning of therapy was 1.45 years. Subgroup comparison indicated that patients with a short duration between symptom onset and diagnosis were significantly younger than patients with a long duration. However, patients with a short duration between symptom onset and diagnosis were at an older age when they reported first symptoms of OCD. Further, they showed less severe symptoms of OCD, higher functioning levels, and less self-stigmatization than patients with a long duration. It can be concluded that the duration until patients with OCD are diagnosed correctly and receive adequate treatment is still very long. Therefore, the duration between symptom onset and diagnosis should be shortened. Further, the duration between diagnosis and the beginning of therapy could be a good additional approach to reduce the overall duration of untreated disorder.

Acceptability and Feasibility of the Transfer of Face-to-Face Group Therapy to Online Group Chats in a Psychiatric Outpatient Setting During the COVID-19 Pandemic: Longitudinal Observational Study

BACKGROUND

At the height of the COVID-19 pandemic, several mental health care providers were obliged to shut down outpatient services, including group therapy and psychoeducational sessions. The lockdown in many countries is a serious threat to people's mental well-being, especially for individuals with severe mental illnesses. Discontinued outpatient treatments and disruption of daily routines are considered to be risk factors for destabilization of patients with mental illness.

OBJECTIVE

The aim of this study was to evaluate the acceptability, usability, and feasibility of a group chat program to replace cancelled face-to-face group sessions in an outpatient psychiatric department.

METHODS

Participants (N=33) were recruited in the outpatient department of a large university medical center in Leipzig, Germany. Former face-to-face group participants were invited to take part in a therapist-guided group-chat for 4 weeks (8 sessions) and were asked to evaluate the program via self-administered standardized questionnaires at baseline (T0, preintervention), after every chat session (T1), and posttreatment (T2, after 4-6 weeks). The chat groups were specific to the following mental disorder diagnoses and based on the same therapeutic principles and techniques as the former face-to-face groups: anxiety, depression, obsessive-compulsive disorder, and adult attention-deficit/hyperactivity disorder (ADHD). Sociodemographic measures, attitudes toward the COVID-19 pandemic, depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), treatment credibility/expectancy (Credibility Expectancy Questionnaire), and participants' satisfaction (Client Satisfaction Questionnaire-8 [ZUF-8]) were measured.

RESULTS

Participants joined an average of 5 out of 8 offered chat sessions. Participation rates in the respective groups were highest in the ADHD group (8.6/11, 78%) and lowest in the anxiety group (3.7/9, 41%). The overall preintervention level of depressive symptoms was moderate and showed a slight, nonsignificant improvement at posttreatment (T0: mean 10.7, SD 5.5; T2: mean 10.2, SD 5.5). A similar result was observed regarding quality of life (T0: median 41.7-68.8; T2: median 50-70.3). Treatment credibility and expectancy scores were medium-high (T0: meancredibility 18.1, SD 3.8; meanexpectancy 11.2, SD 5.1; T2: meancredibility 17.1, SD 4.8; meanexpectancy 10.3, SD 5.8). Further, significant correlations were detected between posttreatment expectancy score and posttreatment PHQ-9 score (r=-0.41, P=.02), posttreatment physical quality of life (r=0.54, P=.001), and posttreatment psychological quality of life (r=0.53, P=.002). Overall, participants' satisfaction with the program was very high, both after chat sessions and at posttreatment (ZUF-8: mean score 20.6, SD 1.0). Of all participants, a majority (27/31, 87%) rated the program as excellent/good and indicated they would recommend the group chat program to a friend in need of similar help (23/31, 74%).

CONCLUSIONS

A therapist-guided group chat program to substitute outpatient group setting treatment during the COVID-19 lockdown was shown to be feasible, usable, and highly acceptable for participants. Web-based programs such as this one provide an easy-to-implement tool to successfully stabilize participants during a difficult time, such as the COVID-19 pandemic.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00021527; https://tinyurl.com/3btyxc2r.

"Doctor, my back hurts and I cannot sleep." Depression in primary care patients: Reasons for consultation and perceived depression stigma

Background

General practitioners (GPs) play a significant role in depression care. Recognition of depression is crucial for adequate treatment but is impeded by a high portion of depressed patients only reporting physical symptoms to their GP. Among the many reasons for this phenomenon is mental health stigma. We investigated how patients with depression differed from patients without depression regarding the types and number of complaints presented to their GP, as well as their depression stigma. For the subgroup of patients with depression, potential associations between perceived depression stigma and number and types of presented complaints were investigated to see if these might reflect the patient’s intention to conceal mental health symptoms due to fear of being stigmatized by others. Further, we investigated if perceived depression stigma is related to depression treatment.

Methods

Data on depressive symptoms (assessed by the Depression Screening Questionnaire; DSQ), depression stigma (assessed by the Depressions Stigma Scale; DSS), type of complaints reported to the GP and treatment-related factors were collected from 3,563 unselected primary care patients of 253 GPs in a cross-sectional epidemiological study (“VERA study”) in six different German regions. Data of a total of 3,069 patients was used for analysis on complaints reported to the GP (subsample of the VERA study), and for 2,682 out of 3,069 patients data on a stigma questionnaire was available.

Results

Nearly half of the primary care patients with depression (42.2%) reported only physical complaints to their GP. Compared to patients without a depression diagnosis, patients with depression reported twice as many complaints to their GP with a mean of 2.02 (1.33) vs. 1.2 (0.69), including a more frequent combination of physical and mental symptoms (28.8% vs. 3.5%). Patients with depression showed higher total stigma compared to patients without depression, Mdn = 48 (IQR 40–54) vs. Mdn = 46.3 (IQR 29–53), due to higher perceived stigma, Mdn = 27 (IQR 21–32) vs. Mdn = 25.9 (IQR 20–29). Perceived stigma was associated with male gender (beta -.14, p = .005) and a lack of pharmacological treatment (beta -.14, p = .021) in patients with a depression diagnosis.

Conclusion

The number of complaints presented to the GP might function as a marker to actively explore depression in primary care patients, in particular when both physical and mental symptoms are reported. Perceived depression stigma should also be addressed especially in male patients. Further research should clarify the role of perceived stigma as a potential inhibitor of pharmacological treatment of depression in primary care.

Mental Health, Social and Emotional Well-Being, and Perceived Burdens of University Students During COVID-19 Pandemic Lockdown in Germany

Background: The COVID-19 pandemic has been affecting everyone's daily life in unknown measures since its outbreak. Nearly all Universities around the globe were affected. Further, young people and University students in particular, are known to be vulnerable for developing mental disorders. This study aims to examine the mental health social and emotional well-being and perceived burdens of University students during COVID-19 pandemic lockdown in Germany. Materials and Methods: This cross-sectional and anonymous online survey among University students assessed mental health status with standardized measures (depressive symptoms, alcohol and drug consumption, and eating disorder symptoms), attitudes toward the COVID-19 pandemic and perceived burdens, and social and emotional aspects of the pandemic (social support, perceived stress, loneliness, and self-efficacy). Results: In total, N = 3,382 German University students participated. Nearly half of the students (49%) reported that they are worried or very much worried about the COVID-19 pandemic. The majority supports the governmental lockdown measures (85%). A Patient Health Questionnaire-9 (PHQ-9) sum score of 10 or above, indicating clinically relevant depressive symptoms, was reported by 37% (n = 1,249). The PHQ-9 sum score was on average 8.66 (SD = 5.46). Suicidal thoughts were indicated by 14.5% of the participants. Levels of depressive symptoms differed significantly for the different self-rated income changes during the pandemic (increase, decrease, no change in income). Further, levels of depressive symptoms and suicidal ideation differed significantly for students from different faculties. Multiple regression analyses revealed that not being a parent, having no indirect social contact one or two times a week, higher perceived stress, higher experienced loneliness, lower social support, and lower self-efficacy significantly predicted higher scores of depressive symptoms, also higher hazardous alcohol use, and higher levels of eating disorder symptoms. Other aspects of lifestyle such as social and cultural activities, dating, and hobbies were reported to be negatively affected during the pandemic. Conclusion: The present study implies that University students are vulnerable and due to elevated depressive symptoms at risk, being hit hard by the pandemic, but are in general coping adaptively. Low-threshold online interventions promoting help-seeking and also targeting various mental health conditions might bridge the gap the COVID-19 pandemic opened up recently.

Efficacy of a Guided Web-Based Self-Management Intervention for Depression or Dysthymia: Randomized Controlled Trial With a 12-Month Follow-Up Using an Active Control Condition

BACKGROUND

An increasing number of studies suggest that web-based interventions for patients with depression can reduce their symptoms and are expected to fill currently existing treatment gaps. However, evidence for their efficacy has mainly been derived from comparisons with wait-list or treatment as usual controls. In particular, designs using wait-list controls are unlikely to induce hope and may even have nocebo effects, making it difficult to draw conclusions about the intervention's efficacy. Studies using active controls are rare and have not yielded conclusive results.

OBJECTIVE

The main objective of this study is to assess the acute and long-term antidepressant efficacy of a 6-week, guided, web-based self-management intervention building on the principles of cognitive behavioral therapy (iFightDepression tool) for patients with depression compared with web-based progressive muscle relaxation as an active control condition.

METHODS

A total of 348 patients with mild-to-moderate depressive symptoms or dysthymia (according to the Mini International Neuropsychiatric Interview) were recruited online and randomly assigned to 1 of the 2 intervention arms. Acute antidepressant effects after 6 weeks and long-term effects at 3-, 6-, and 12-month follow-up were studied using the Inventory of Depressive Symptomatology-self-rating as a primary outcome parameter and change in quality of life (Short Form 12) and user satisfaction (client satisfaction questionnaire) as secondary outcome parameters. Treatment effects were assessed using mixed model analyses.

RESULTS

Over the entire observation period, a greater reduction in symptoms of depression (P=.01) and a greater improvement of life quality (P<.001) was found in the intervention group compared with the active control group. Separate tests for each time point revealed significant effects on depressive symptoms at the 3-month follow-up (d=0.281; 95% CI 0.069 to 0.493), but not after 6 weeks (main outcome:d=0.192; 95% CI -0.020 to 0.404) and 6 and 12 months. The intervention was significantly superior to the control condition with respect to user satisfaction (25.31 vs 21.97; t₂₅₉=5.804; P<.01).

CONCLUSIONS

The fact that antidepressant effects have been found for a guided self-management tool in comparison with an active control strengthens the evidence base for the efficacy of web-based interventions. The antidepressant effect became most prominent at the 3-month follow-up. After 6 weeks of intervention, significant positive effects were observed on life quality but not on depressive symptoms. Although the effect size of such web-based interventions on symptoms of depression might be smaller than that suggested by earlier studies using wait-list control conditions, they can be a cost-effective addition to antidepressants and face-to-face psychotherapy.

TRIAL REGISTRATION

International Clinical Trials Registry Platform ICTRP080-15-09032015; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00009323.

Utilization of e-mental-health and online self-management interventions of patients with mental disorders-A cross-sectional analysis

Background

Web-based treatments and online self-management interventions extend the range of therapeutic supply. Since the number of online self-management interventions is steadily increasing, we aimed to examine, how web-based services currently influence mental health care, asking about previous internet use and future interests of patients with mental disorders.

Methods

We consulted patients (n = 400) from all services of the Department of Psychiatry and Psychotherapy of the University of Leipzig using a 28-item questionnaire. Overall, 301 questionnaires could be used for analysis. The data were analysed by means of descriptive statistics and group comparisons.

Results

The majority of patients (98.3%) were using the internet. Data revealed younger patients were searching for information on diseases (p < .001; M = 35.7 ±13.2), psychiatrists (p < .001; M = 34.6 ±11.6) and exchange with other patients (p < .001; M = 32 ±10.6) more often than older patients. We also found the internet was consulted more often regarding the search for information (p = .011; M = 58.3 ±10.9) and psychiatrists (p < .001; M = 35.7 ±13.2) the lower the patients’ level of functioning was. While only a small proportion (10.1%) of the sample had used online self-management interventions before, there is a far greater number (46.1%) who stated an interest to use online self-management interventions in the future. This interest was greater in patients who were younger (p < .001; M = 33.8 ±13.2) had a higher education level (p = .003; university degree = 59.2%, high school degree = 52.3%; mandatory school degree: 34.8%).

Conclusions

While only a small percentage of patients uses online self-management interventions, there is a far greater interest to include them into the treatment. Further research has to investigate how the integration of web-based services into the whole treatment process can be optimized. In addition, standardized diagnostic methods have to be found to evaluate the needs and experiences of patients.

Gender differences in patient and caregiver psychoeducation for schizophrenia

Objective:

The aim of this research is to detect gender-related differences in patients and caregivers regarding knowledge about schizophrenia and attitudes towards drugs as well as gender as predictor for changes in these variables during psychoeducation.

Methods:

Data sets of one randomised-controlled (study 1) and one naturalistic psychoeducation study (study 2) were reanalysed. Main outcome measures (knowledge about schizophrenia, drug attitude, confidence in medication) were assessed at baseline, post-intervention and 12 months after index discharge.

Results:

The reanalysed samples consisted in total of 1002 patients and 176 caregivers. In study 2, baseline knowledge was significantly better in male patients and female caregivers. All participants improved significantly their knowledge. The amount of knowledge gain did not differ between genders in either study or either group. Gender was not a major predictor of baseline knowledge or knowledge gain. Only in study 1 did gender significantly impact the knowledge gain from baseline to follow-up. Regarding improvement of drug attitude, females seemed to benefit significantly better from psychoeducation. In both studies, however, changes in drug attitudes respectively confidence in medication were best explained by lower corresponding baseline scores, not gender. Patients’ gender did not influence outcomes of their caregivers.

Conclusion:

Our findings suggest that psychoeducational programs might be better adapted to males in order to improve their drug attitude. Concerning knowledge, gender-related changes do not seem to be necessary.

Associations of Suicide Rates With Socioeconomic Status and Social Isolation: Findings From Longitudinal Register and Census Data

Suicide represents a major challenge to public mental health. In order to provide empirical evidence for prevention strategies, we hypothesized current levels of low socioeconomic status (SES) and high social isolation (SI) to be linked to increased suicide rates in N = 390 administrative districts since SES and SI are associated with mental illness. Effects of SES on suicide rates were further expected to be especially pronounced in districts with individuals showing high SI levels as SI reduces the reception of social support and moderates the impact of low SES on poor mental health. We linked German Microcensus data to register data on all 149,033 German suicides between 1997 and 2010 and estimated Prentice and Sheppard's model for aggregate data to test the hypotheses, accounting for spatial effect correlations. The findings reveal increases in district suicide rates by 1.20% (p < 0.035) for 1% increases of district unemployment, suicide rate decreases of -0.39% (p < 0.028) for 1% increases in incomes, increases of 1.65% (p < 0.033) in suicides for 1% increases in one-person-households and increases in suicide rates of 0.54% (p < 0.036) for 1% decreases in single persons' incomes as well as suicide rate increases of 3.52% (p < 0.000) for 1% increases in CASMIN scores of individuals who moved throughout the year preceding suicide. The results represent appropriate starting points for the development of suicide prevention strategies. For the definition of more precise measures, future work should focus on the causal mechanisms resulting in suicidality incorporating individual level data.

GET.HAPPY2 - User perspectives on an internet-based self-management positive psychology intervention among persons with and without depression: Results from a retrospective survey

OBJECTIVE

Previous research suggests that online positive psychology interventions (PPI) are frequently used by individuals with symptoms of depression. We aimed to investigate differences in the way depressed and nondepressed users react to the content of an existing online PPI, originally designed for the general public.

METHOD

In a retrospective online survey, we assessed discontinuation parameters, aspects of satisfaction with the program, and negative reactions among users of an online PPI.

RESULTS

Bivariate and multivariate analyses showed that, overall, reactions between depressed and nondepressed individuals were similar. Differences were observed concerning reasons for using and for discontinuing the program, the perception of exercises, and negative reactions.

CONCLUSIONS

Although satisfaction with the program was high, it did not seem to fully meet users' expectations and might be more difficult to complete during episodes of depression. Implications of this study for the adaptation of online PPIs addressing depressed individuals are discussed.

Depression stigma and management of suicidal callers: a cross-sectional survey of crisis hotline counselors

BACKGROUND

Crisis hotlines play a key role in suicide prevention worldwide following different approaches regarding risk assessment and management of suicidality. This is to our knowledge the first study investigating depression stigma in crisis hotline counselors. The association between stigma and self-rated knowledge and their exploration of suicide risk and consecutive management of suicidal callers is being investigated.

METHODS

Data on depression stigma, self-rated knowledge, self-reported exploration and management of suicidality was collected from 893 counselors working for the German crisis hotline. Stigma in counselors had been compared to matched population sample (1002).

RESULTS

Crisis hotline counselors reported significantly lower depression stigma compared to the general population. Depression stigma and age associations differed in both samples. The reported exploration of suicide risk in callers differed depending on the self-rated knowledge about suicidality and depending on the personal depression stigma, but not the reported consecutive management.

CONCLUSION

Compared to the general population, crisis hotline counselors seem to have fewer stigmatizing attitudes toward depression. Attitudes and self-rated knowledge seem to influence the confidence in counselors regarding the exploration of suicidal callers, but not the consecutive management. The results indicate that a profound training and hands-on information about depression and suicide risk seem to be essential.

[How frequently are depressive disorders recognized in primary care patients? : A cross-sectional epidemiological study in Germany]

BACKGROUND

Primary care physicians (PCPs) play a crucial role for guideline-oriented intervention in patients with depression.

OBJECTIVES

Based on a diagnostic screening questionnaire, this study investigates the sensitivity of PCPs to recognize patients with depression as well as the factors facilitating recognition and concordant diagnostic decisions.

METHOD

In a cross-sectional epidemiological study in six regions of Germany, 3563 unselected patients filled in questionnaires on mental and physical complaints and were diagnostically evaluated by their PCP (N = 253). The patient reports on an established Depression-Screening-Questionnaire (DSQ), which allows the approximate derivation of an ICD-10 depression diagnosis, were compared with the physician diagnosis (N = 3211). In a subsample of discordant cases a comprehensive standardized clinical-diagnostic interview (DIA-X/CIDI) was applied.

RESULTS

On the study day, the prevalence of ICD-10 depression was 14.3% according to the DSQ and 10.7% according to the physician diagnosis. Half of the patients identified by DSQ were diagnosed with depression by their physician and two thirds were recognized as mental disorder cases. More severe depression symptomatology and the persistent presence of main depression symptoms were related to better recognition and concordant diagnostic decisions. Diagnostic validation interviews confirmed the DSQ diagnosis in the majority of the false-negative cases. Indications for at least a previous history of depression were found in up to 70% of false-positive cases.

CONCLUSION

Given the high prevalence of depression in primary care patients, there is continued need to improve the recognition and diagnosis of these patients to assure guideline-oriented treatment.

Efficacy of an internet-based self-management intervention for depression or dysthymia - a study protocol of an RCT using an active control condition

BACKGROUND

The treatment of major depressive disorder, a highly prevalent disorder associated with pronounced burden, is a large challenge to healthcare systems worldwide. Internet based self-management interventions seem to be a cost effective way to complement the treatment of depressed patients, but the accumulating evidence is mainly based on the comparison to waitlist controls and treatment as usual, which might lead to an overestimation of effects. Furthermore, studies assessing long-term effects and possible negative outcomes are still rare.

METHODS/DESIGN

The proposed study evaluates the efficacy of the German version of the iFightDepression® tool in comparison to an active control condition. A total of 360 patients with mild to moderate depressive symptoms are included into a two-armed randomized controlled trial. They receive one of two six week interventions; either the iFightDepression® tool or progressive muscle relaxation serving as the control condition. Both intervention groups receive information material, weekly tasks via the internet and regular phone calls as part of the intervention. The primary outcome is change in depressive symptoms after the intervention period, as measured with the Inventory of Depressive Symptomatology. Satisfaction with the program, usability, changes in perceived quality of life, and possible negative effects are assessed as secondary outcomes.

DISCUSSION

This study represents the first randomized controlled trial on the iFightDepression® self-management tool in its German version, aiming at efficacy, but also at providing new insights into so far understudied aspects of E-mental health programs, namely the specificity of the treatment effect compared to an active control condition, it's continuity over a time course of 12 months, and possible negative effects of these internet based interventions.

TRIAL REGISTRATION

International trial-registration took place through the "international clinical trials registry platform" (WHO) with the secondary ID 080-15-09032015. German Clinical Trial Registration: DRKS00009323 (DRKS.de, registered on 25 February 2016).

Promoting Help-seeking using E-technology for ADolescents with mental health problems: study protocol for a randomized controlled trial within the ProHEAD Consortium

BACKGROUND

The highest incidence and prevalence of mental health problems across the lifespan as well as the first onset of most long-term mental health conditions are reported for youths between 14 and 25 years of age. At the same time, only 25% of adolescents with mental health problems receive professional treatment. One explanation for poor treatment access in youths is their low help-seeking behavior. Barriers that can keep children and adolescents (C&A) from seeking professional help include a lack of perceived need, structural barriers, or stigma. Interventions based on e-technology might present an effective approach, overcoming these barriers by reducing stigma and providing low-threshold access with enhanced reach, ultimately facilitating help-seeking for mental health problems among youths.

METHODS

The study is designed as a multi-center, randomized controlled trial. In total, an estimated number of n = 1,500 C&A with mental health problems, drawn from a school-based sample of n = 15,000 pupils attending school grades 6 to 13 (≥ 12 years of age), recruited in five regions of Germany, will be randomized either to an intervention (ProHEAD online) or a control condition. C&A in the intervention group will receive online access to tailored information and individual advice on where to seek professional help for their specific needs close to their place of living, case reports of and interaction with peers, as well as the opportunity for online and telephone counseling. C&A in the control intervention will receive a recommendation to seek help and online information on where to find professional help. All participants will be asked to complete questionnaires concerning their help-seeking behavior at baseline, during the intervention (monitoring), and also at a 1 and 2 year follow-up. The primary endpoint is the number of C&A seeking conventional face-to-face professional help in the real-world setting within 1 year after their initial screening.

DISCUSSION

The trial will investigate if an Internet-based intervention can increase professional help-seeking in C&A with mental health problems. With its randomized controlled design and large-scale school-based sampling, the study aims to overcome the shortages of previous research. The intervention has the potential to narrow the treatment gap in C&A and to ultimately improve the mental health care system.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014685 . Registered on 7 July, 2018.

Effectiveness of a web-based screening and brief intervention with weekly text-message-initiated individualised prompts for reducing risky alcohol use among teenagers: study protocol of a randomised controlled trial within the ProHEAD consortium

BACKGROUND

Early and excessive alcohol use is a significant threat to healthy development. Evidence supports the effectiveness of electronic alcohol interventions for young drinkers. However, effects are typically small and studies targeting under 18-year-olds are scarce. This trial is the first to evaluate the effectiveness of a single-session, brief, motivational, web-based intervention (ProWISE) plus weekly text-message-initiated individualised prompts (TIPs) in reducing alcohol consumption and alcohol-related harm among children and adolescents aged ≥ 12 years. TIPs are designed to decrease risky alcohol use by reaching youth in the contexts of their everyday lives and by providing individualised feedback on drinking intentions, actual drinking and succession in achieving personal goals for low-risk drinking or abstinence.

METHODS/DESIGN

The trial is part of the multicentre consortium ProHEAD testing e-interventions for mental health problems in children and adolescents. Participants in grades 6-13 aged ≥ 12 years will be recruited in schools which participate in ProHEAD (target N = 15,000). Main criterion for inclusion in the ProWISE-TIP trial is a positive screening for at-risk alcohol use in the CRAFFT-d questionnaire (target n = 1076). In a multicentre, four-arm, randomised controlled design the following groups will be compared: (A) web-based intervention plus TIPs for 12 weeks; (B) web-based intervention plus text-message-initiated assessment of alcohol consumption for 12 weeks; (C) web-based intervention only; and (D) alcohol-related psychoeducation. TIPs will be delivered shortly before and after high-risk situations for excessive alcohol use and will be tailored to age, gender, drinking motives and alcohol consumption. Study participants will be followed up at three, six and nine months in the ProWISE-TIP trial and at one and two years in the ProHEAD consortium. Primary outcome is alcohol use in the past 30 days at nine months after enrolment. Secondary outcomes are alcohol-related problems, co-occurring substance use, health service utilisation, mental health problems and quality of life.

DISCUSSION

Trial results will generate important evidence on how to enhance effectiveness of single-session, web-based alcohol interventions for youth. The ProWISE-TIP intervention, if effective, can be used as a stand-alone alcohol intervention or as an add-on to school-based or community-based alcohol prevention programs.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014606 Registered on 20 April 2018.

School-based mental health promotion in children and adolescents with StresSOS using online or face-to-face interventions: study protocol for a randomized controlled trial within the ProHEAD Consortium

BACKGROUND

Schools are an ideal setting in which to promote health. However, empirical data on the effectiveness of school-based mental health promotion programs are rare, and research on universal Internet-based prevention in schools is almost non-existent. Following the life skills approach, stress management training is an important component of health promotion. Mental health literacy is also associated with mental health status, and it facilitates formal help-seeking by children and adolescents (C&A). The main objectives of this study are (1) the development and evaluation of an Internet-based version of a universal school-based health promotion program called StresSOS and (2) demonstrating non-inferiority of the online setting compared to the face-to-face setting. StresSOS aims to improve stress management and mental health literacy in C&A.

METHODS/DESIGN

A school-based sample of 15,000 C&A (grades 6-13 and older than 12 years) will be recruited in five regions of Germany within the ProHEAD Consortium. Those with a screening result at baseline indicating no mental health problems will be invited to participate in a randomized controlled trial comparing StresSOS online to an active online control condition (Study A). In addition, 420 adolescents recruited as a separate school-based sample will participate in the StresSOS face-to-face intervention. Participants in both intervention groups (online or face-to-face) will receive the same eight treatment modules to allow for the comparison of both methods of delivery (Study B). The primary outcome is the number of C&A with symptoms of mental health problems at a 12 months follow-up. Secondary outcomes are related to stress/coping (i.e., knowledge, symptoms of stress, coping resources), mental health literacy (knowledge and attitudes toward mental disorders and help-seeking), program usage patterns, cost-effectiveness, and acceptability of the intervention.

DISCUSSION

This study represents the first adequately powered non-inferiority trial in the area of school-based mental health promotion. If online StresSOS proves efficacious and non-inferior to face-to-face delivery, this offers great potential for health promotion in youths, both in and outside the school environment.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014693 . Registered on 14 May 2018.

Efficacy and cost-effectiveness of two online interventions for children and adolescents at risk for depression (E.motion trial): study protocol for a randomized controlled trial within the ProHEAD consortium

BACKGROUND

Depression is a serious mental health problem and is common in children and adolescents. Online interventions are promising in overcoming the widespread undertreatment of depression and in improving the help-seeking behavior in children and adolescents.

METHODS

The multicentre, randomized controlled E.motion trial is part of the German ProHEAD consortium (Promoting Help-seeking using E-technology for ADolescents). The objective of the trial is to investigate the efficacy and cost-effectiveness of two online interventions to reduce depressive symptomatology in high-risk children and adolescents with subsyndromal symptoms of depression in comparison to an active control group. Participants will be randomized to one of three conditions: (1) Intervention 1, a clinician-guided self-management program (iFightDepression®); (2) Intervention 2, a clinician-guided group chat intervention; and (3) Control intervention, a psycho-educational website on depressive symptoms. Interventions last six weeks. In total, N = 363 children and adolescents aged ≥ 12 years with Patient Health Questionnaire-9 modified for Adolescents (PHQ-A) scores in the range of 5-9 will be recruited at five study sites across Germany. Online questionnaires will be administered before onset of the intervention, at the end of the intervention, and at the six-month follow-up. Further, children and adolescents will participate in the baseline screening and the one- and two-year school-based follow-up assessments integrated in the ProHEAD consortium. The primary endpoint is depression symptomatology at the end of intervention as measured by the PHQ-A score. Secondary outcomes include depression symptomatology at all follow-ups, help-seeking attitudes, and actual face-to-face help-seeking, adherence to and satisfaction with the interventions, depression stigma, and utilization and cost of interventions.

DISCUSSION

This study represents the first randomized controlled trial (RCT) investigating efficacy and cost-effectiveness of two online interventions in children and adolescents aged ≥ 12 years at risk for depression. It aims to provide a better understanding of the help-seeking behavior of children and adolescents, potential benefits of E-mental health interventions for this age group, and new insights into so far understudied aspects of E-mental health programs, such as potential negative effects of online interventions. This knowledge will be used to tailor and improve future help offers and programs for children and adolescents and ways of treatment allocation.

TRIAL REGISTRATION

German Register for Clinical Trials (DRKS), DRKS00014668 . Registered on 4 May 2018. International trial registration took place through the "international clinical trials registry platform" with the secondary ID S-086/2018.

GET.HAPPY - Acceptance of an internet-based self-management positive psychology intervention for adult primary care patients with mild and moderate depression or dysthymia: A pilot study

INTRODUCTION

A growing number of internet interventions have been shown to help in alleviating symptoms of depression. So far, only little research has focused on other methods than CBT. The present study aimed to investigate the level of satisfaction with a positive psychology online training among patients with mild and moderate depression or dysthymia. Secondary outcome measures included changes in symptom severity, health related quality of life, and negative effects.

METHODS

A total of 81 participants were allocated to the intervention. They were asked to complete online questionnaires and were called by one of the study psychologists at baseline, at post-treatment, and at follow-up (3 months after completion of the intervention). Shorter questionnaires were administered after each module.

RESULTS

Overall satisfaction was promising. While participants seemed to be very satisfied with many aspects of the program itself, they were slightly less satisfied with its impact on the problems they sought to solve. Overall, negative effects attributed to the program were small with one exception. At post-treatment, 22.6% of the participants felt that they or their problems were not taken seriously by the program. Symptom severity decreased over time with mild to moderate effect sizes. There was a moderate increase in satisfaction with mental health at both post-treatment and follow-up.

CONCLUSIONS

The online program investigated here may be a useful resource-oriented addition to the standard treatment of depression.

Minor depression in older, long-term unemployed people seeking vocational support

BACKGROUND

Prevalence rates of minor and major depression vary from 0.7 to 6.8 (minor) and 3.8 to 10.9 (major) for the general population. Twenty-two percent of older, long-term unemployed people suffer from major depression. However, the prevalence rate of minor depression (depression on a subthreshold level with less than 5, but more than 1 depression symptom) in this population is unknown. The first aim of this study is to identify that prevalence rate, because we already know that minor depression increases the risk of developing a major depression and this in turn reduces the chances of reemployment what increases social and individual costs at the same time. The second aim is to find out whether there are symptoms that distinguish the different groups "no depression", "minor depression" and "major depression" in this population. In contrast to the general population, the most frequent symptoms within major and minor depression in older, long-term unemployed people are unknown so far.

METHODS

A total of 234 long-term unemployed people (response rate 59%) were included in a study within a project of the Department of Psychiatry and Psychotherapy at the University of Leipzig and an unemployment agency. Based on the results of the Patient Health Questionnaire, the participants were classified as non depressive, minor depressive or major depressive. Descriptive statistics and chi-square tests were performed to identify whether there are symptoms stated by the participants that are more frequent than others, and if the classified groups differ in this regard.

RESULTS

Fifty percent had no depression, 15.6% had a minor depression and 34.4% were suffering from major depression. Difficulty with concentration is the symptom that differentiated the last two groups the most. Fatigue, depressed mood and anhedonia were the symptoms that distinguished participants with minor depression the most from participants with no depression. Main limitations are: The sample was determined by programme conditions, e.g. not all potentially available people participated. The sample may therefore not be representative for the general long-term unemployed. Due to limited resources the PHQ 9 was used instead of a clinical interview to assess minor and major depression.

CONCLUSIONS

Results indicate that minor depression in older, long-term unemployed persons is significant, as, almost 16% of the participants were affected in the study. Especially when fatigue is present for a period of more than 2 weeks, people should be informed about the option to consult a primary care physician or professionals from the unemployment agency in order to prevent the possible onset of major depression.

A cross-national study on gender differences in suicide intent

BACKGROUND

Suicide accounts for over 58,000 deaths in Europe per annum, where suicide attempts are estimated to be 20 times higher. Males have been found to have a disproportionately lower rate of suicide attempts and an excessively higher rate of suicides compared to females. The gender difference in suicide intent is postulated to contribute towards this gender imbalance. The aim of this study is to explore gender differences in suicide intent in a cross-national study of suicide attempts. The secondary aims are to investigate the gender differences in suicide attempt across age and country.

METHODS

Data on suicide attempts (acquired from the EU-funded OSPI-Europe project) was obtained from eight regions in Germany, Hungary, Ireland and Portugal. Suicide intent data was categorized into 'Non-habitual Deliberate Self-Harm' (DSH), 'Parasuicidal Pause' (SP), 'Parasuicidal Gesture' (SG), and 'Serious Suicide Attempt' (SSA), applying the Feuerlein scale. Gender differences in intent were explored for significance by using χ²-tests, odds ratios, and regression analyses.

RESULTS

Suicide intent data from 5212 participants was included in the analysis. A significant association between suicide intent and gender was found, where 'Serious Suicide Attempts' (SSA) were rated significantly more frequently in males than females (p < .001). There was a statistically significant gender difference in intent and age groups (p < .001) and between countries (p < .001). Furthermore, within the most utilised method, intentional drug overdose, 'Serious Suicide Attempt' (SSA) was rated significantly more often for males than females (p < .005).

CONCLUSIONS

Considering the differences in suicidal intent between males and females highlighted by the current study, gender targeted prevention and intervention strategies would be recommended.

Research Recommendations for Improving Measurement of Treatment Effectiveness in Depression

Background: Despite the steadily escalating psychological and economic burden of depression, there is a lack of evidence for the effectiveness of available interventions on functioning areas beyond symptomatology. Therefore, the main objective of this study was to give an insight into the current measurement of treatment effectiveness in depression and to provide recommendations for its improvement.

Materials and Methods: The study was based on a multi-informant approach, comparing data from a systematic literature review, an expert survey with representatives from clinical practice (130), and qualitative interviews with patients (11) experiencing depression.

Results: Current literature places emphasis on symptomatic outcomes and neglects other domains of functioning, whereas clinicians and depressed patients highlight the importance of both. Interpersonal relationships, recreation and daily activities, communication, social participation, work difficulties were identified as being crucial for recovery. Personal factors, neglected by the literature, such as self-efficacy were introduced by experts and patients. Furthermore, clinicians and patients identified a number of differences regarding the areas improved by psychotherapeutic or pharmacological interventions that were not addressed by the pertinent literature.

Conclusion: Creation of a new cross-nationally applicable measure of psychosocial functioning, broader remission criteria, report of domain-specific information, and a personalized approach in treatment decision-making are the first crucial steps needed for the improvement of the measurement of treatment effectiveness in depression. A better measurement will facilitate the clinical decision making and answer the escalating burden of depression.

Effects of culture-sensitive adaptation of patient information material on usefulness in migrants: a multicentre, blinded randomised controlled trial

OBJECTIVES

To evaluate the usefulness of culture-sensitive patient information material compared with standard translated material.

DESIGN

Multicentre, double-blind randomised controlled trial.

SETTING

37 primary care practices.

PARTICIPANTS

435 adult primary care patients with a migration background with unipolar depressive disorder or non-specific chronic low back pain were randomised. Patients who were unable to read in the language of their respective migration background were excluded. Sufficient data were obtained from 203 women and 106 men. The largest group was of Russian origin (202 patients), followed by those of Turkish (52), Polish (30) and Italian (25) origin.

INTERVENTIONS

Intervention group: provision of culture-sensitive adapted material.

CONTROL GROUP

provision of standard translated material.

MAIN OUTCOME MEASURES

Primary outcome: patient-rated usefulness (USE) assessed immediately after patients received the material.

SECONDARY OUTCOMES

patient-rated usefulness after 8 weeks and 6 months, symptoms of depression (PHQ-9), back pain (Back Pain Core Set) and quality of life (WHO-5) assessed at all time points.

RESULTS

Usefulness was found to be significantly higher (t=1.708, one-sided p=0.04) in the intervention group (USE-score=65.08, SE=1.43), compared with the control group (61.43, SE=1.63), immediately after patients received the material, in the intention-to-treat analysis, with a mean difference of 3.65 (one-sided 95% lower confidence limit=0.13). No significant differences were found for usefulness at follow-up (p=0.16, p=0.71). No significant effect was found for symptom severity in depression (p=0.95, p=0.66, p=0.58), back pain (p=0.40, p=0.45, p=0.32) or quality of life (p=0.76, p=0.86, p=0.21), either immediately after receiving the material, or at follow-up (8 weeks; 6 months). Patients with a lower level of dominant society immersion benefited substantially and significantly more from the intervention than patients with a high level of immersion (p=0.005).

CONCLUSION

Cultural adaptation of patient information material provides benefits over high quality translations. Clinicians are encouraged to use culture-sensitive material in their consultations, particularly with low-acculturated patients.

TRIAL REGISTRATION NUMBER

German Register for Clinical Trials: DRKS00004241, Universal Trial Number: U1111-1135-8043, Results.

Internet-Delivered Disease Management for Recurrent Depression: A Multicenter Randomized Controlled Trial

BACKGROUND

Strategies to improve the life of patients suffering from recurrent major depression have a high relevance. This study examined the efficacy of 2 Internet-delivered augmentation strategies that aim to prolong symptom-free intervals.

METHODS

Efficacy was tested in a 3-arm, multicenter, open-label, evaluator-blind, randomized controlled trial. Upon discharge from inpatient mental health care, 232 adults with 3 or more major depressive episodes were randomized to 1 of 2 intervention groups (SUMMIT or SUMMIT-PERSON) or to treatment as usual (TAU) alone. Over 12 months, participants in both intervention arms received, in addition to TAU, intense monitoring via e-mail or a smartphone, including signaling of upcoming crises, assistance with personal crisis management, and facilitation of early intervention. SUMMIT-PERSON additionally offered regular expert chats. The primary outcome was 'well weeks', i.e. weeks with at most mild symptoms assessed by the Longitudinal Interval Follow-Up Evaluation, during 24 months after the index treatment.

RESULTS

SUMMIT compared to TAU reduced the time with an unwell status (OR 0.48; 95% CI 0.23-0.98) through faster transitions from unwell to well (OR 1.44; 95% CI 0.83-2.50) and slower transitions from well to unwell (OR 0.69; 95% CI 0.44-1.09). Contrary to the hypothesis, SUMMIT-PERSON was not superior to either SUMMIT (OR 0.77; 95% CI 0.38-1.56) or TAU (OR 0.62; 95% CI 0.31-1.24). The efficacy of SUMMIT was strongest 8 months after the intervention.

CONCLUSIONS

The fully automated Internet-delivered augmentation strategy SUMMIT has the potential to improve TAU by reducing the lifelong burden of patients with recurrent depression. The fact that the effects wear off suggests a time-unlimited extension.

The role of socio-economic status in depression: results from the COURAGE (aging survey in Europe)

BACKGROUND

Low socio-economic status (SES) has been found to be associated with a higher prevalence of depression. However, studies that have investigated this association have been limited in their national scope, have analyzed different components of SES separately, and have not used standardized definitions or measurements across populations. The aim of the current study was to evaluate the association between SES and depression across three European countries that represent different regions across Europe, using standardized procedures and measurements and a composite score for SES.

METHOD

Nationally-representative data on 10,800 individuals aged ≥18 from the Collaborative Research on Ageing in Europe (COURAGE) survey conducted in Finland, Poland and Spain were analyzed in this cross-sectional study. An adapted version of the Composite International Diagnostic Interview was used to identify the presence of depression, and SES was computed by using the combined scores of the total number of years educated (0-22) and the quintiles of the country-specific income level of the household (1-5). Multivariable logistic regression was used to assess the association between SES and depression.

RESULTS

Findings reveal a significant association between depression and SES across all countries (p ≤ 0.001). After adjusting for confounders, the odds of depression were significantly decreased for every unit increase in the SES index for Finland, Poland and Spain. Additionally, higher education significantly decreased the odds for depression in each country, but income did not.

CONCLUSION

The SES index seems to predict depression symptomatology across European countries. Taking SES into account may be an important factor in the development of depression prevention strategies across Europe.

[From the First Symptoms of Depression to Treatment. When and Where are People Seeking Help? Does Stigma Play a Role? - Results from a Survey at a German Convention for People with Depression]

Objective Only a few of the people affected by depression receive early treatment. The aim of this study is to determine the time interval between first onset of symptoms and treatment utilization and the role of stigma in this process. Methods Survey with participants from the 2nd German Patient Convention in Leipzig, Germany for patients, relatives and the general public. Results About one fourth of the respondents stated that the time interval between first symptoms of depression and treatment utilization was longer than three years. One third said that they received treatment immediately or until up to three months after the first symptoms of depression, and one third after three months up to three years. The majority (64 %) said that they first received a depression diagnosis from a specialist. The most common treatments used were psychotherapy, pharmacotherapy and a combination of both. Self-help, physical activity and occupational therapy were named as the most popular non-medical treatments. Conclusion A possible explanation for delayed treatment utilization could be the perceived public stigma, which was higher in people with depression in comparison to other convention attendees (relatives and general public).

Community-based 4-level approach: Background, implementation and evidence for efficacy

The community-based 4-level-intervention concept developed within the “European Alliance against Depression” (http://www.eaad.net/) combines two important aims: to improve the care and treatment of patients with depression and to prevent suicidal behavior. It has been shown to be effective concerning the prevention of suicidal behavior [1–4] and is worldwide the most broadly implemented community-based intervention targeting depression and suicidal behavior. The 4-level intervention concept comprises training and support of primary care providers (level 1), a professional public relation campaign (level 2), training of community facilitators (teacher, priests, geriatric caregivers, pharmacists, journalists) (level 3), and support for self-help of patients with depression and for their relatives (level 4). In order to deepen the understanding of factors influencing the effectiveness of the intervention, a systematic implementation research and process analysis was performed within the EU-funded study “Optimizing Suicide Prevention Programs and Their Implementation in Europe” (http://www.ospi-europe.com/; 7th Framework Programme) [5]. These analyses were based on data from four intervention and four control regions from four European countries. In addition to intervention effects on suicidal behaviour, a variety of intermediate outcomes (e.g. changes in attitude or knowledge in different populations) were considered. Strong synergistic as well as catalytic effects were identified as a result of being active simultaneously at four different levels. Predictable and unpredictable obstacles to a successful implementation of such community-based programs will be discussed. Via the EAAD, the intervention concept and materials (available in eight different languages) are offered to interested region in and outside of Europe.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Celebrity suicide on the railway network: Can one case trigger international effects?

BACKGROUND

After the railway suicide of the German national goalkeeper Robert Enke in 2009, a significant increase of railway suicides was observed nationally. This study analyses whether this incident also triggered copycat effects in other European countries. Additionally, media coverage proxied by Google Trends and long-term changes taking into account general changes in suicide rates and kilometres driven by trains were examined.

METHODS

The numbers of railway suicides before and after Enke´s suicide were analysed for short and long-term periods (2 weeks and 2 years post-event) across five European countries. Incidence ratios and resulting percentage changes were computed.

RESULTS

Similar to Germany, there were significant short and long-term effects for the combined data of the four other countries (increase of 93.9%; p=0.004 and 16.7%; p=0.003). There was no indication that long-term effects are a mere reflection of an overall increase in suicide frequencies or due to increased numbers of kilometres driven by trains. Analyses on country level revealed heterogeneous results.

LIMITATIONS

Due to incomplete data, analyses regarding age and gender were not performed. Media coverage was only proxied by a Google Trends analysis. The study includes a small sample of European countries.

CONCLUSIONS

Enke's suicide in 2009 was followed by increasing train suicide numbers in Europe. Although this incident may have reinforced an existing European trend of growing railway suicides, an international copycat effect and/or an increased overall awareness about this particular suicide method appears to be one likely explanation for the changes.

[Psychoeducation in Depression: Results of two Surveys five Years Apart in Germany, Austria and Switzerland]

OBJECTIVE

Studies investigating the frequency of psychoeducation in depression for patients and their family members in hospital settings and assessing how psychoeducation is offered are lacking.

METHODS

Two postal surveys were done five years apart addressing these questions to the heads of all psychiatric hospitals in Germany, Austria and Switzerland.

RESULTS

67 % of the participating hospitals offered psychoeducation in depression. 60 % of the patients treated in the hospitals participated in psychoeducation groups, whereas only 13 % of the family members did. In the mean, a single psychoeducational session lasted for 61 minutes (SD = 14), took place 1.4-times per week (SD = 0.5) and there were 7.4 sessions (SD = 2.8). 56 % of the moderators of the psychoeducational groups used a published manual for conducting the groups.

CONCLUSION

The frequency of offering psychoeducation in depression for patients is almost comparable to that in schizophrenia. However, there is still room for improvement, especially when it comes to family psychoeducation in depression where all efforts need to be done to increase the number of groups offered in order to inform more families and help them coping with depression.