Anxiety and depression symptoms in adolescents and young adults with juvenile idiopathic arthritis: results of an outpatient screening

BACKGROUND

Previous studies have shown that growing up with rheumatic conditions can fuel dissatisfaction and psychological distress, which in turn affects disease self-management and treatment adherence. Primary objective of this study was to estimate the prevalence of anxiety and depression symptoms in adolescents and young adults (AYA) with juvenile idiopathic arthritis (JIA) and to identify correlates of conspicuous screening results.

METHODS

Initiated as part of the COACH multicenter observational study, outpatients aged 12 to 21 years participating in the National Pediatric Rheumatological Database (NPRD) were prospectively screened for mental health using the Patient Health Questionnaire-9 (PHQ-9) and the Generalised Anxiety Disorder Scale-7 (GAD-7).

RESULTS

Data from 1,150 adolescents with JIA (mean age 15.6 ± 2.2 years; mean disease duration 7.2 ± 4.9 years, 69% female, 43% oligoarthritis, 26% polyarthritis) were analysed. Overall, 32.7% (n = 316) of AYA showed conspicuous screening results, of whom 30.4% reported clinically relevant suicidal or self-harm thoughts. About 19% of screened patients showed moderate to severe depressive or anxious symptoms. AYA with conspicuous screening results were older (15.8 vs. 15.2 years; p < 0.0001), more often female (81% vs. 64%; p < 0.0001) and more often overweight (25% vs. 17%; p = 0.006). They had higher disease activity (physician global assessment on NRS 0-10; 1.7 vs. 1.2; p < 0.0001), more functional limitations (CHAQ; 0.44 vs. 0.14; <0.0001) and rated their health status worse (NRS 0-10; 3.5 vs. 1.8; p < 0.0001) than AYA with inconspicuous screening results. Females (OR 2.33 [CI 1.53-3.56]; p < 0.0001), older age (OR 1.09 [CI 1.01-1.18]; p = 0.026), patients with more functional limitations (OR 3.36 [CI 1.98-5.72]; p < 0.0001), and patients with worse subjective health status (OR 1.17 [CI 1.07-1.27]; p < 0.0001) were more likely to have a conspicuous screening result. Regular sports participation was associated with a lower likelihood of conspicuous screening result (OR 0.69 [CI 0.49-0.98]; p = 0.039).

CONCLUSIONS

A large-scale outpatient screening of AYA with JIA in Germany shows a high prevalence of anxiety and depression symptoms. The need for routine screening for early detection of mental health problems became apparent.

Predicting effects of a digital stress intervention for patients with depressive symptoms: Development and validation of meta-analytic prognostic models using individual participant data

OBJECTIVE

Digital stress interventions could be helpful as an "indirect" treatment for depression, but it remains unclear for whom this is a viable option. In this study, we developed models predicting individualized benefits of a digital stress intervention on depressive symptoms at 6-month follow-up.

METHOD

Data of N = 1,525 patients with depressive symptoms (Center for Epidemiological Studies' Depression Scale, CES-D ≥ 16) from k = 6 randomized trials (digital stress intervention vs. waitlist) were collected. Prognostic models were developed using multilevel least absolute shrinkage and selection operator and boosting algorithms, and were validated using bootstrap bias correction and internal-external cross-validation. Subsequently, expected effects among those with and without a treatment recommendation were estimated based on clinically derived treatment assignment cut points.

RESULTS

Performances ranged from R² = 21.0%-23.4%, decreasing only slightly after model optimism correction (R² = 17.0%-19.6%). Predictions were greatly improved by including an interim assessment of depressive symptoms (optimism-corrected R2 = 32.6%-35.6%). Using a minimally important difference of d = -0.24 as assignment cut point, approximately 84.6%-93.3% of patients are helped by this type of intervention, while the remaining 6.7%-15.4% would experience clinically negligible benefits (δ^ = -0.02 to -0.19). Using reliable change as cut point, a smaller subset (39.3%-46.2%) with substantial expected benefits (δ^ = -0.68) receives a treatment recommendation.

CONCLUSIONS

Meta-analytic prognostic models applied to individual participant data can be used to predict differential benefits of a digital stress intervention as an indirect treatment for depression. While most patients seem to benefit, the developed models could be helpful as a screening tool to identify those for whom a more intensive depression treatment is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Impact of COVID-19 Pandemic on Mental Health of Adolescents With Chronic Medical Conditions: Findings From a German Pediatric Outpatient Clinic

PURPOSE

The impact of the COVID-19 pandemic on the mental health of adolescents is of great concern, especially in the vulnerable group of adolescents with chronic medical conditions. The aim of this study was to examine this impact on the mental health of adolescents with chronic medical conditions treated in a German pediatric outpatient clinic.

METHODS

Changes in the mental health status of adolescents with chronic medical conditions treated in a German pediatric outpatient clinic during the COVID-19 pandemic were explored via validated screening tools for anxiety and depression.

RESULTS

The relative risk for adolescents with chronic medical conditions to develop clinically relevant symptoms of anxiety or depression was significantly higher (odds ratio 1,78 [confidence interval 1.06-3.04]) during the pandemic.

DISCUSSION

This study identifies the COVID-19 pandemic as a potential additional risk for adolescents with chronic medical conditions to develop clinically relevant signs of anxiety or depression.

Internet- and mobile-based anxiety and depression interventions for children and adolescents: efficacy and negative effects - a systematic review and meta-analysis

Mental disorders, most commonly anxiety disorders and fourth most common depression, are prevalent in children and adolescents. Internet- and mobile-based interventions might represent a scalable approach to improve mental health care, however, evidence so far is inconclusive and systematic reports on negative effects are missing. Four data-bases were searched for randomized controlled trials evaluating internet- and mobile-based interventions (IMIs) targeting anxiety disorders or depression in children and adolescents up to 18 years exhibiting clinically relevant symptoms. Meta-analytic evaluations were conducted in comparison to active and passive control groups, furthermore, pre-defined sub-groups were explored and reported negative effects examined. Pooled estimates showed a moderate positive effect for IMIs targeting anxiety disorders compared to passive control groups (g = -0.69; CI -0.94 to -0.45; k = 8; n = 559; p ≤ 0,001), but not for depression. Pooled estimates compared to active control groups remained non-significant. Subgroup analyses were largely omitted due to an insufficient number of trials or were non-significant. Negative effects were mainly reported as drop-out rates and (non)-response rates, while additional negative effects, such as deterioration rates or the development of additional symptoms, were reported by only one third of included studies. The focus on children and adolescents with clinically relevant symptoms allowed the present findings to complement previous work, however, the limited amount of trials hindered many planned comparisons. The overview of reported negative effects highlighted that negative effects are being neglected in the majority of RCTs. Hence, in the future RCTs should include more information about potential negative effects, at best a combination of quantitative and qualitative information. Open Science Framework (osf.io/ch5nj).

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Additive effects of adjunctive app-based interventions for mental disorders - A systematic review and meta-analysis of randomised controlled trials

Background

It is uncertain whether app-based interventions add value to existing mental health care.

Objective

To examine the incremental effects of app-based interventions when used as adjunct to mental health interventions.

Methods

We searched PubMed, PsycINFO, Scopus, Web of Science, and Cochrane Library databases on September 15th, 2023, for randomised controlled trials (RCTs) on mental health interventions with an adjunct app-based intervention compared to the same intervention-only arm for adults with mental disorders or respective clinically relevant symptomatology. We conducted meta-analyses on symptoms of different mental disorders at postintervention. PROSPERO, CRD42018098545.

Results

We identified 46 RCTs (4869 participants). Thirty-two adjunctive app-based interventions passively or actively monitored symptoms and behaviour, and in 13 interventions, the monitored data were sent to a therapist. We found additive effects on symptoms of depression (g = 0.17; 95 % CI 0.02 to 0.33; k = 7 comparisons), anxiety (g = 0.80; 95 % CI 0.06 to 1.54; k = 3), mania (g = 0.2; 95 % CI 0.02 to 0.38; k = 4), smoking cessation (g = 0.43; 95 % CI 0.29 to 0.58; k = 10), and alcohol use (g = 0.23; 95 % CI 0.08 to 0.39; k = 7). No significant effects were found on symptoms of depression within a bipolar disorder (g = -0.07; 95 % CI -0.37 to 0.23, k = 4) and eating disorders (g = -0.02; 95 % CI -0.44 to 0.4, k = 3). Studies on depression, mania, smoking, and alcohol use had a low heterogeneity between the trials. For other mental disorders, only single studies were identified. Only ten studies had a low risk of bias, and 25 studies reported insufficient statistical power.

Discussion

App-based interventions may be used to enhance mental health interventions to further reduce symptoms of depression, anxiety, mania, smoking, and alcohol use. However, the effects were small, except for anxiety, and limited due to study quality. Further high-quality research with larger sample sizes is warranted to better understand how app-based interventions can be most effectively combined with established interventions to improve outcomes.

Mental health services for German university students: acceptance of intervention targets and preference for delivery modes

Introduction

Most university students with mental disorders remain untreated. Evaluating the acceptance of intervention targets in mental health treatment, promotion, and prevention, as well as mental health service delivery modes is crucial for reducing potential barriers, increasing healthcare utilization, and efficiently allocating resources in healthcare services.

Aim

The study aimed to evaluate the acceptance of various intervention targets and delivery modes of mental health care services in German first-year university students.

Methods

In total, 1,376 first-year students from two German universities from the 2017-2018 multi-center cross-sectional cohort of the StudiCare project, the German arm of the World Mental Health International College Student Survey initiative, completed a web-based survey assessing their mental health. Mental disorder status was based on self-reported data fulfilling the DSM-IV criteria. We report frequencies of accepted delivery modes [categories: group or in-person therapy with on or off campus services, self-help internet- or mobile-based intervention (IMI) with or without coaching, or a combination of a in-person and IMI (blended)]. In a multinomial logistic regression, we estimate correlates of the preference for in-person vs. IMI vs. a combination of both modes (blended) modalities. Additionally, we report frequencies of intervention targets (disorder specific: e.g., social phobia, depressive mood; study-related: test anxiety, procrastination; general well-being: sleep quality, resilience) their association with mental disorders and sex, and optimal combinations of treatment targets for each mental illness.

Results

German university students' acceptance is high for in-person (71%-76%), moderate for internet- and mobile-based (45%-55%), and low for group delivery modes (31%-36%). In-person treatment (72%) was preferred over IMI (19%) and blended modalities (9%). Having a mental disorder [odds ratio (OR): 1.56], believing that digital treatments are effective (OR: 3.2), and showing no intention to use services (OR: 2.8) were associated with a preference for IMI compared to in-person modes. Students with prior treatment experience preferred in-person modes (OR: 0.46). In general, treatment targets acceptance was higher among female students and students with mental disorders. However, this was not true for targets with the highest (i.e., procrastination) and the lowest (i.e., substance-use disorder) acceptance. If only two intervention targets were offered, a combination of study-related targets (i.e., procrastination, stress, time management) would reach 85%-88% of the students.

Conclusion

In-person services are preferred, yet half of the students consider using IMI, preferably aiming for a combination of at least two study-related intervention targets. Student mental health care services should offer a combination of accepted targets in different delivery modes to maximize service utilization.

Testing a model of benefit-finding and growth in youths with chronic health conditions

BACKGROUND

The experience of benefit-finding and growth (BFG), defined as perceiving positive life changes resulting from adversity, is increasingly studied among youths with chronic health conditions (CCs). However, empirical evidence is scarce for explaining individual differences in BFG. The study aimed to test a model of BFG, including an interplay of personal and environmental factors and coping processes.

METHODS

A sample of N = 498 youths (12-21 years) recruited from three German patient registries for CCs (type 1 diabetes: n = 388, juvenile idiopathic arthritis: n = 82, cystic fibrosis: n = 28) completed a questionnaire including self-reported optimism, social support from parents and peers, coping strategies, and BFG. The model was created to reflect the theoretical assumptions of the Life Crisis and Personal Growth model and current empirical evidence. Structural equation modeling was conducted to evaluate the incremental explanatory power of optimism, peer group integration, parental support, acceptance, cognitive reappraisal, and seeking social support over and above sociodemographic and disease-related characteristics.

RESULTS

The model (CFI = 0.93; RMSEA = 0.04; SRMR = 0.05) explained 32% of the variance in BFG. Controlling for sociodemographic and disease-related characteristics, acceptance, cognitive reappraisal, and seeking social support were directly and positively linked to BFG. All tested coping strategies significantly mediated the association between optimism and BFG, whereas seeking social support significantly mediated the relation between peer group integration and BFG.

DISCUSSION

The study stresses the prominent role of emotion-focused coping strategies and peer group integration in enhancing BFG in youths with CCs.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), no. DRKS00025125. Registered on May 17, 2021.

Outpatient screening for anxiety and depression symptoms in adolescents with type 1 diabetes - a cross-sectional survey

BACKGROUND

The daily demands of type 1 diabetes management may jeopardize adolescents' mental health. We aimed to assess anxiety and depression symptoms by broad-scale, tablet-based outpatient screening in adolescents with type 1 diabetes in Germany.

METHODS

Adolescent patients with type 1 diabetes mellitus (n = 2,394; mean age 15.4 y [SD 2.0]; 50.7% male) were screened for anxiety (GAD-7) and depression symptoms (PHQ-9) by self-report questionnaires and linked to clinical data from the DPV patient registry. Logistic regression was used to estimate the contribution of clinical parameters to positive screening results.

RESULTS

Altogether, 30.2% showed a positive screening (score ≥ 7 in either test), and 11.3% reported suicidal ideations or self-harm. Patients with anxiety and depression symptoms were older (15.7 y [CI 15.5-15.8] vs. 15.3 y [CI 15.2-15.4]; p < 0.0001), had higher HbA1c levels (7.9% [CI 7.8-8.0] (63 mmol/mol) vs. 7.5% [CI 7.4-7.5] (58 mmol/mol); p < 0.0001), and had higher hospitalization rates. Females (adjusted odds ratio (aOR) 2.66 [CI 2.21-3.19]; p < 0.0001), patients > 15 years (aOR 1.40 [1.16-1.68]; p < 0.001), who were overweight (aOR 1.40 [CI 1.14-1.71]; p = 0.001), with HbA1c > 9% (> 75 mmol/mol; aOR 2.58 [1.83-3.64]; each p < 0.0001), with a migration background (aOR 1.46 [CI 1.17-1.81]; p < 0.001), or smoking (aOR 2.72 [CI 1.41-5.23]; p = 0.003) had a higher risk. Regular exercise was a significant protective factor (aOR 0.65 [CI 0.51-0.82]; p < 0.001). Advanced diabetes technologies did not influence screening outcomes.

CONCLUSIONS

Electronic mental health screening was implemented in 42 centers in parallel, and outcomes showed an association with clinical parameters from sociodemographic, lifestyle, and diabetes-related data. It should be integrated into holistic patient counseling, enabling early recognition of mild mental health symptoms for preventive measures. Females were disproportionally adversely affected. The use of advanced diabetes technologies did not yet reduce the odds of anxiety and depression symptoms in this cross-sectional assessment.

How to promote usage of telehealth interventions for farmers' mental health? A qualitative study on supporting and hindering aspects for acceptance and satisfaction with a personalized telephone coaching for depression prevention

Low-threshold and remotely delivered preventive interventions, like telephone coaching, are warranted for farmers who experience multiple risk factors for depression, live in underserved areas, and show low help-seeking behavior. Factors facilitating uptake and actual use of effective remote interventions are important to reduce depression disease burden. This study aimed at identifying factors that potentially can influence acceptance of and satisfaction with a telephone coaching in this occupational group.Semi-structured interviews were based on the 'Unified Theory of Acceptance and Use of Technology', the 'Evaluation', and 'Discrepancy' models for satisfaction. Interviews were conducted with 20 of 66 invited participants of a 6-months telephone coaching during an effectiveness or implementation study. Audio-recorded interviews were transcribed and analyzed (deductive-inductive qualitative content analysis). Independent coding by two persons resulted in good agreement (Κ = 0.80). Participants validated results via questionnaire.Overall, 32 supporting (SF) and 14 hindering factors (HF) for acceptance and satisfaction were identified and organized into five dimensions: Coaching result (SF = 9, HF = 3), coach (SF = 9, HF = 1), organization (SF = 5, HF = 2), the telephone as communication medium (SF = 4, HF = 5) and participant characteristics (SF = 5, HF = 3). Most named SFs were 'Flexible appointment arrangement' (n = 19/95 %) and 'low effort' (n = 17/85 %), while most reported HFs were 'lack of visual cues' (n = 12/60 %) and 'social/professional involvement restricts change process' (n = 10/50 %).The perceived changes initiated by coaching, a low effort through telephone conduct, and the indicated personalization were identified as important influencing factors on acceptance and satisfaction based on interviewees' statements. Both may be further enhanced by offering choice and advice for delivery formats (e.g., video-calls) and training of coaches in farm-related issues.

Study registration

German Clinical Trial Registrations: DRKS00017078 and DRKS00015655.

A (Sub)field Guide to Quality Control in Hippocampal Subfield Segmentation on Highresolution T2-weighted MRI

Inquiries into properties of brain structure and function have progressed due to developments in magnetic resonance imaging (MRI). To sustain progress in investigating and quantifying neuroanatomical details in vivo, the reliability and validity of brain measurements are paramount. Quality control (QC) is a set of procedures for mitigating errors and ensuring the validity and reliability of brain measurements. Despite its importance, there is little guidance on best QC practices and reporting procedures. The study of hippocampal subfields in vivo is a critical case for QC because of their small size, inter-dependent boundary definitions, and common artifacts in the MRI data used for subfield measurements. We addressed this gap by surveying the broader scientific community studying hippocampal subfields on their views and approaches to QC. We received responses from 37 investigators spanning 10 countries, covering different career stages, and studying both healthy and pathological development and aging. In this sample, 81% of researchers considered QC to be very important or important, and 19% viewed it as fairly important. Despite this, only 46% of researchers reported on their QC processes in prior publications. In many instances, lack of reporting appeared due to ambiguous guidance on relevant details and guidance for reporting, rather than absence of QC. Here, we provide recommendations for correcting errors to maximize reliability and minimize bias. We also summarize threats to segmentation accuracy, review common QC methods, and make recommendations for best practices and reporting in publications. Implementing the recommended QC practices will collectively improve inferences to the larger population, as well as have implications for clinical practice and public health.

Effects of a Web-Based Behavioral Activation Intervention on Depressive Symptoms, Activation, Motivation, and Volition: Results of a Randomized Controlled Trial

INTRODUCTION

Behavioral activation (BA) is effective for the treatment of depression. The Health Action Process Approach (HAPA), which is derived from health psychology, can provide a motivational-volitional framework of BA.

OBJECTIVE

This study investigated the efficacy of a HAPA-based internet-delivered BA intervention (iBA; called InterAKTIV) in individuals with depression, also assessing HAPA-based motivational and volitional outcomes.

METHODS

In a two-arm randomized controlled efficacy trial with a parallel design, 128 participants with a major depressive episode were randomly allocated to the intervention group (IG; TAU + immediate access to iBA) or control group (CG; TAU + access to iBA after follow-up). The primary outcome of clinician-rated depressive symptoms and secondary outcomes were assessed at baseline (T1), 8 weeks (T2), 6-month after randomization (T3). Data were analyzed on an intention-to-treat basis.

RESULTS

Linear mixed model analyses revealed a significant group*time interaction effect on clinician-rated depressive symptoms favoring the IG (F2, 156.0 = 7.40; p < 0.001, d = 0.79 at T2, d = 0.25 at T3). The IG was also superior regarding self-rated depressive symptoms, BA, most motivational, and all volitional outcomes.

CONCLUSION

This study shows that HAPA-based iBA can significantly improve clinician-rated depressive symptoms, as well as outcomes used in the HAPA model in people with depression. Building on these efficacy results, in the next step, the relationship between BA interventions and activity levels should be investigated, taking into account motivation and volition as potential mediators.

Blending Video Therapy and Digital Self-Help for Individuals With Suicidal Ideation: Intervention Design and a Qualitative Study Within the Development Process

BACKGROUND

Digital formats have the potential to enhance accessibility to care for individuals with suicidal ideation. However, digital self-help interventions have faced limitations, including small effect sizes in reducing suicidal ideation, low adherence, and safety concerns.

OBJECTIVE

Therefore, we aimed to develop a remote blended cognitive behavioral therapy intervention that specifically targets suicidal ideation by blending video therapy with web-based self-help modules. The objective of this paper is to describe the collaborative development process and the resulting intervention and treatment rationale.

METHODS

First, we compiled intervention components from established treatment manuals designed for people with suicidal ideation or behavior, resulting in the development of 11 drafts of web-based modules. Second, we conducted a qualitative study, involving 5 licensed psychotherapists and 3 lay counselors specialized in individuals with suicidal ideation who reviewed these module drafts. Data were collected using the think-aloud method and semistructured interviews, and a qualitative content analysis was performed. The 4 a priori main categories of interest were blended care for individuals with suicidal ideation, contents of web-based modules, usability of modules, and layout. Subcategories emerged inductively from the interview transcripts. Finally, informed by previous treatment manuals and qualitative findings, we developed the remote blended treatment program.

RESULTS

The participants suggested that therapists should thoroughly prepare the web-based therapy with patients to tailor the therapy to each individual's needs. Participants emphasized that the web-based modules should explain concepts in a simple manner, convey empathy and validation, and include reminders for the safety plan. In addition, participants highlighted the need for a simple navigation and layout. Taking these recommendations into account, we developed a fully remote blended cognitive behavioral therapy intervention comprising 12 video therapy sessions and up to 31 web-based modules. The treatment involves collaboratively developing a personalized treatment plan to address individual suicidal drivers.

CONCLUSIONS

This remote treatment takes advantage of the high accessibility of digital formats while incorporating full sessions with a therapist. In a subsequent pilot trial, we will seek input from individuals with lived experience and therapists to test the feasibility of the treatment.

StudiCare procrastination - Randomized controlled non-inferiority trial of a persuasive design-optimized internet- and mobile-based intervention with digital coach targeting procrastination in college students

BACKGROUND

Academic procrastination is widespread among college students. Procrastination is strongly negatively correlated with psychological well-being, thus early interventions are needed. Internet- and mobile-based cognitive behavioral therapy (iCBT) could provide a low-threshold treatment option. Human guidance seems to be a decisive mechanism of change in iCBT. Persuasive design optimization of iCBT and guidance by a digital coach might represent a resource-saving alternative. The study evaluated the non-inferiority of a digital coach in comparison to human guidance with regard to the primary outcome procrastination.

METHODS

The iCBT StudiCare procrastination was optimized by principles of the Persuasive System Design (PSD). A total of 233 college students were randomly assigned to either StudiCare procrastination guided by a digital coach (intervention group, IG) or by a human eCoach (control group, CG). All participants were assessed at baseline, 4-, 8- and 12-weeks post-randomization. Symptom change and between-group differences were assessed with latent growth curve models and supported by effect size levels. The non-inferiority margin was set at Cohen's d = - 0.3.

RESULTS

The primary outcome procrastination measured by the Irrational Procrastination scale (IPS) significantly decreased across groups (γ = - 0.79, p < .001, Cohen's d = -0.43 to -0.89) from baseline to 12-weeks post-randomization. There were no significant differences between groups (γ = -0.03, p = .84, Cohen's d = -0.03 to 0.08). Regarding symptoms of depression, no significant time x group effect was found (γ = 0.26, p = .09; Cohen's d = -0.15 to 0.21). There was also no significant time x group effect on the improvement of symptoms of anxiety (γ = 0.25, p = .09). However, Cohen's ds were above the non-inferiority margin 8-weeks (Cohen's d = 0.51) and 12-weeks post-randomization (Cohen's d = 0.37), preferring the CG. Of the IG, 34% and of the CG, 36% completed 80% of the modules.

CONCLUSIONS

The PSD optimized version of StudiCare procrastination is effective in reducing procrastination. The digital coach was not inferior to human guidance. Guidance by a digital coach in iCBT against procrastination for college students could be a resource-saving alternative to human guidance.

TRIAL REGISTRATION

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trial Register (ID: DRKS00025209, 30/04/2021).

Remote blended treatment for individuals with suicidal ideation: A single-arm proof-of-concept trial

INTRODUCTION

New digital treatment formats may reduce barriers to treatment for individuals with suicidal ideation. This study aimed to investigate the feasibility of a remote blended care programme for this population, defined as acceptability, demand, practicality, adaptation, indications of efficacy and safety.

METHODS

We conducted a mixed-methods single-arm trial for proof-of-concept. Participants were eligible if they were at least 18 years old, had sufficient German proficiency, a Beck Scale for Suicidal Ideation score ≥2, internet access and lived near the outpatient clinic. The treatment consisted of 12 sessions of cognitive-behavioural videotherapy combined with online modules over 6 weeks.

RESULTS

We included 10 participants. All patients were satisfied with the treatment; most patients (80%) reported unpleasant memories resurfacing. All patients completed all therapy sessions and a mean of 13.7 modules (SD = 5.7); three patients switched to face-to-face treatment, in one case due to safety concerns. All patients and most therapists (83.3%) found the treatment overall practicable. Most patients (66.7%) and therapists (66.7%) considered remote treatment equivalent to face-to-face therapy. There were no serious adverse events.

CONCLUSION

While promising, the results suggest changes to the programme might be needed, particularly for patients' safety. A controlled feasibility trial should investigate temporary deteriorations.

Predicting heterogeneous treatment effects of an Internet-based depression intervention for patients with chronic back pain: Secondary analysis of two randomized controlled trials

Background

Depression is highly prevalent among individuals with chronic back pain. Internet-based interventions can be effective in treating and preventing depression in this patient group, but it is unclear who benefits most from this intervention format.

Method

In an analysis of two randomized trials (N = 504), we explored ways to predict heterogeneous treatment effects of an Internet-based depression intervention for patients with chronic back pain. Univariate treatment-moderator interactions were explored in a first step. Multilevel model-based recursive partitioning was then applied to develop a decision tree model predicting individualized treatment benefits.

Results

The average effect on depressive symptoms was d = -0.43 (95 % CI: -0.68 to -0.17; 9 weeks; PHQ-9). Using univariate models, only back pain medication intake was detected as an effect moderator, predicting higher effects. More complex interactions were found using recursive partitioning, resulting in a final decision tree with six terminal nodes. The model explained a large amount of variation (bootstrap-bias-corrected R2 = 45 %), with predicted subgroup-conditional effects ranging from di = 0.24 to -1.31. External validation in a pilot trial among patients on sick leave (N = 76; R2 = 33 %) pointed to the transportability of the model.

Conclusions

The studied intervention is effective in reducing depressive symptoms, but not among all chronic back pain patients. Predictions of the multivariate tree learning model suggest a pattern in which patients with moderate depression and relatively low pain self-efficacy benefit most, while no benefits arise when patients' self-efficacy is already high. If corroborated in further studies, the developed tree algorithm could serve as a practical decision-making tool.

Mechanisms of change in digital cognitive behavioral therapy for depression in patients with chronic back pain: A mediation analysis of a multicenter randomized clinical trial

BACKGROUND

While there is evolving knowledge on change processes of digital cognitive behavioral therapy (CBT) in the treatment of depression, little is known about how these interventions produce therapeutic change in the comorbid constellation of chronic back pain (CBP). Here, we examined whether the effects of a digital intervention to treat depression in patients with CBP are mediated by three pain-related variables (i.e., pain self-efficacy, pain-related disability, pain intensity).

METHODS

This study is a secondary analysis of a randomized clinical trial conducted in routine care at 82 orthopedic clinics across Germany. In total, 209 adults with CBP and diagnosed depression (SCID interview) were randomly assigned to the intervention (n = 104) or treatment-as-usual (n = 105). Cross-lagged mediation models were estimated to investigate longitudinal mediation effects of putative mediators with depression symptom severity (PHQ-9) as primary outcome at post-treatment.

RESULTS

Longitudinal mediation effects were observed for pain self-efficacy (ß = -0.094, 95%-CI [-0.174, -0.014], p = 0.021) and pain-related disability (ß = -0.068, 95%-CI [-0.130, -0.001], p = 0.047). Furthermore, the hypothesized direction of the mediation effects was supported, reversed causation did not occur. Pain intensity did not reveal a mediation effect.

CONCLUSIONS

The results suggest a relevant role of pain self-efficacy and pain-related disability as change processes in the treatment of depression for patients with CBP in routine care. However, further research is needed to disclose potential reciprocal relationships of mediators, and to extend and specify our knowledge of the mechanisms of change in digital CBT for depression.

Internet-Based Treatment of Body Dysmorphic Disorder: Feasibility, Evaluation, and Self-Report Data

ABSTRACT

Initial findings indicate the effectiveness of internet-based interventions for body dysmorphic disorder (BDD). In order to substantiate these findings, a seven-module guided internet-based intervention was created and examined. We report the mixed data of participants with clinical and subclinical BDD of the treatment group (n = 18). We investigated the feasibility, the quality of the program content, the design and usability, and its effects on symptom severity and related psychopathology. Adherence to the intervention was low and dropout rate high (55.6%). The program content, perceived website usability, and visual aesthetic were rated high. Credibility and expectancy were on a medium level. Satisfaction with appearance improved significantly in the intention-to-treat analysis (d = 0.58). In sum, symptom-related outcomes and program evaluation showed a positive trend albeit the study conduction was difficult. Future programs should investigate the role of additional motivation strategies and more flexible support addressing the known treatment barriers.

Stress Management Apps: Systematic Search and Multidimensional Assessment of Quality and Characteristics

BACKGROUND

Chronic stress poses risks for physical and mental well-being. Stress management interventions have been shown to be effective, and stress management apps (SMAs) might help to transfer strategies into everyday life.

OBJECTIVE

This review aims to provide a comprehensive overview of the quality and characteristics of SMAs to give potential users or health professionals a guideline when searching for SMAs in common app stores.

METHODS

SMAs were identified with a systematic search in the European Google Play Store and Apple App Store. SMAs were screened and checked according to the inclusion criteria. General characteristics and quality were assessed by 2 independent raters using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality (range 1 to 5) on the following four dimensions: (1) engagement, (2) functionality, (3) esthetics, and (4) information. In addition, the theory-based stress management strategies, evidence base, long-term availability, and common characteristics of the 5 top-rated SMAs were assessed and derived.

RESULTS

Of 2044 identified apps, 121 SMAs were included. Frequently implemented strategies (also in the 5 top-rated SMAs) were psychoeducation, breathing, and mindfulness, as well as the use of monitoring and reminder functions. Of the 121 SMAs, 111 (91.7%) provided a privacy policy, but only 44 (36.4%) required an active confirmation of informed consent. Data sharing with third parties was disclosed in only 14.0% (17/121) of the SMAs. The average quality of the included apps was above the cutoff score of 3.5 (mean 3.59, SD 0.50). The MARS-G dimensions yielded values above this cutoff score (functionality: mean 4.14, SD 0.47; esthetics: mean 3.76, SD 0.73) and below this score (information: mean 3.42, SD 0.46; engagement: mean 3.05, SD 0.78). Most theory-based stress management strategies were regenerative stress management strategies. The evidence base for 9.1% (11/121) of the SMAs could be identified, indicating significant group differences in several variables (eg, stress or depressive symptoms) in favor of SMAs. Moreover, 38.0% (46/121) of the SMAs were no longer available after a 2-year period.

CONCLUSIONS

The moderate information quality, scarce evidence base, constraints in data privacy and security features, and high volatility of SMAs pose challenges for users, health professionals, and researchers. However, owing to the scalability of SMAs and the few but promising results regarding their effectiveness, they have a high potential to reach and help a broad audience. For a holistic stress management approach, SMAs could benefit from a broader repertoire of strategies, such as more instrumental and mental stress management strategies. The common characteristics of SMAs with top-rated quality can be used as guidance for potential users and health professionals, but owing to the high volatility of SMAs, enhanced evaluation frameworks are needed.

Case report for an internet- and mobile-based intervention for internet use disorder

BACKGROUND AND AIMS

Internet use disorder (IUD), characterized as the inability to control one's internet use, is associated with reduced quality of life and mental health comorbidities such as depression, substance abuse, or anxiety. Evidence-based treatment options are scarce due to the novelty of the diagnosis. Internet- and mobile-based interventions (IMI) may be an effective means to deliver psychological treatment to individuals with IUD as they address affected individuals in their online setting. This study presents a newly developed IMI for IUD disclosing treatment satisfaction and preliminary effects by exemplifying with a case report.

METHODS

The case of a female participant with IUD, characterized by an excessive use of social media, is analyzed. The case report follows the CARE guidelines and presents qualitative and quantitative outcomes regarding potential symptom reduction measured by the Internet Addiction Test (IAT) and Compulsive Internet Use Scale (CIUS), treatment satisfaction measured by the Client Satisfaction Questionnaire (CSQ) and feasibility by analyzing participant's written feedback during treatment.

RESULTS

The case report shows that internet- and mobile-based interventions may be feasible in supporting an individual in reducing symptoms of IUD as well as depressive symptoms, anxiety and procrastination behavior. Treatment satisfaction was reported as good.

DISCUSSION AND CONCLUSIONS

This case report illustrates that IMIs can have the potential to be an easily accessible and possibly effective treatment option for IUD. Case studies on IMIs may provide insights into important mechanisms for symptom change. Further studies are needed to expand our understanding of this diverse disorder to provide adequate treatment.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/,DRKS00015314.

Acceptance of smart sensing: a barrier to implementation-results from a randomized controlled trial

Background

Accurate and timely diagnostics are essential for effective mental healthcare. Given a resource- and time-limited mental healthcare system, novel digital and scalable diagnostic approaches such as smart sensing, which utilizes digital markers collected via sensors from digital devices, are explored. While the predictive accuracy of smart sensing is promising, its acceptance remains unclear. Based on the unified theory of acceptance and use of technology, the present study investigated (1) the effectiveness of an acceptance facilitating intervention (AFI), (2) the determinants of acceptance, and (3) the acceptance of adults toward smart sensing.

Methods

The participants (N = 202) were randomly assigned to a control group (CG) or intervention group (IG). The IG received a video AFI on smart sensing, and the CG a video on mindfulness. A reliable online questionnaire was used to assess acceptance, performance expectancy, effort expectancy, facilitating conditions, social influence, and trust. The self-reported interest in using and the installation of a smart sensing app were assessed as behavioral outcomes. The intervention effects were investigated in acceptance using t-tests for observed data and latent structural equation modeling (SEM) with full information maximum likelihood to handle missing data. The behavioral outcomes were analyzed with logistic regression. The determinants of acceptance were analyzed with SEM. The root mean square error of approximation (RMSEA) and standardized root mean square residual (SRMR) were used to evaluate the model fit.

Results

The intervention did not affect the acceptance (p = 0.357), interest (OR = 0.75, 95% CI: 0.42-1.32, p = 0.314), or installation rate (OR = 0.29, 95% CI: 0.01-2.35, p = 0.294). The performance expectancy (γ = 0.45, p < 0.001), trust (γ = 0.24, p = 0.002), and social influence (γ = 0.32, p = 0.008) were identified as the core determinants of acceptance explaining 68% of its variance. The SEM model fit was excellent (RMSEA = 0.06, SRMR = 0.05). The overall acceptance was M = 10.9 (SD = 3.73), with 35.41% of the participants showing a low, 47.92% a moderate, and 10.41% a high acceptance.

Discussion

The present AFI was not effective. The low to moderate acceptance of smart sensing poses a major barrier to its implementation. The performance expectancy, social influence, and trust should be targeted as the core factors of acceptance. Further studies are needed to identify effective ways to foster the acceptance of smart sensing and to develop successful implementation strategies.

Clinical Trial Registration

identifier 10.17605/OSF.IO/GJTPH.

Moderators and mediators of change of an internet-based mindfulness intervention for college students: secondary analysis from a randomized controlled trial

Background

Existing evidence suggests internet- and mobile-based interventions (IMIs) improve depressive symptoms in college students effectively. However, there is far less knowledge about the potential mechanisms of change of mindfulness-based IMIs, which could contribute to optimizing target groups and interventions. Hence, within this secondary analysis of data from a randomized controlled trial (RCT), potential moderators and mediators of the effectiveness of the IMI StudiCare Mindfulness were investigated.

Methods

Moderation and mediation analyses were based on secondary data from a RCT that examined the effectiveness of the 7-module IMI StudiCare Mindfulness in a sample of college students (intervention group: n = 217; waitlist control group: n = 127). Assessments were collected before (t0; baseline), 4 weeks after (t1; during intervention), and 8 weeks after (t2; post-intervention) randomization. Longitudinal mediation analyses using structural equation modeling were employed, with depressive symptom severity as the dependent variable. For moderation analyses, bilinear interaction models were calculated with depressive symptom severity and mindfulness at t2 as dependent variables. All data-analyses were performed on an intention-to-treat basis.

Results

Mediation analyses showed a significant, full mediation of the intervention effect on depressive symptom severity through mindfulness (indirect effect, a*b = 0.153, p < 0.01). Only the number of semesters (interaction: β = 0.24, p = 0.035) was found to moderate the intervention's effectiveness on depressive symptom severity at t2, and only baseline mindfulness (interaction: β = -0.20, p = 0.047) and baseline self-efficacy (interaction: β = -0.27, p = 0.012) were found to be significant moderators of the intervention effect on mindfulness at t2.

Conclusion

Our results suggest a mediating role of mindfulness. Moderation analyses demonstrated that the intervention improved depressive symptom severity and mindfulness independent of most examined baseline characteristics. Future confirmatory trials will need to support these findings.

Clinical Trial Registration

The trial was registered a priori at the WHO International Clinical Trials Registry Platform via the German Clinical Studies Trial Register (TRN: DRKS00014774; registration date: 18 May 2018).

Posttraumatic stress symptoms in adolescents and young adults with a chronic somatic disease: a mixed-methods study

BACKGROUND

Adolescents and young adults (AYA) with a chronic somatic disease (CD) have a 3-fold higher risk of post-traumatic stress disorder (PTSD) than healthy controls. In addition, elevated post-traumatic stress symptoms (PTSS) have a negative impact on CD severity, treatment adherence, health problems and functional impairment. However, a more detailed understanding of this comorbidity is lacking.

METHODS

AYA with type 1 diabetes mellitus, juvenile idiopathic arthritis or cystic fibrosis (12-21 years of age) and elevated anxiety and/or depression symptoms, as well as their reference persons (≥ 18 years of age), completed online questionnaires in self- or observer report. The most stressful event related to the CD was reported descriptively. Questionnaires were used to assess PTSS, anxious and depressive symptoms, actual overall health, coping, personal growth and social support. Qualitative content analysis, linear regression models and correlations were used for mixed methods analysis.

RESULTS

According to the reports of n = 235 AYA (mean age 15.61; 73% girls) and n = 70 reference persons, four categories were identified as the most stressful events due to CD: (1) psychological burden (40% of AYA / 50% of reference persons); (2) CD self-management (32% / 43%); (3) social burden (30% / 27%); and (4) physical impairment (23% / 16%). 37% of AYA reported clinically relevant PTSS due to CD. The best predictors of PTSS severity were anxious-depressive symptoms, emotional coping, personal growth and current overall health (F(4, 224) = 59.404, R² = 0.515, p < .001). Of all categories, psychological (β = 0.216, p = .002) and social burden (β = 0.143, p = .031) showed significant association with the severity of PTSS (F(4, 230) = 4.489, R² = 0.072, p = .002). The more categories the most stressful event addressed, the higher was the PTSS symptom severity (r = .168, p = .010).

CONCLUSIONS

Many AYA showed clinically relevant PTSS and reported experiencing stressful events in several areas of life through their CD. The association between the stressful event categories and other variables could help identify AYA with CD who need psychological interventions the most.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00016714, registered on 25/03/2019 and DRKS00017161, registered on 17/09/201.

Support- and meaning-focused coping as key factors for maintaining adult quality of life during the COVID-19 pandemic in Germany

Introduction

During the COVID-19 pandemic, questions about both consequences and helpful strategies to maintain quality of life (QoL) have become increasingly important. Thus, the aim of this study was to investigate the distribution of coping factors during the COVID-19 pandemic, their associations with QoL and the moderating role of certain sociodemographic characteristics.

Methods

Analyses were based on cross-sectional self-reports from German adult participants (N = 2,137, 18-84 years, 52.1% female) of the CORONA HEALTH APP Study from July 2020 to July 2021. Multivariate regression analyses were used to predict (a) coping factors assessed with the Brief COPE and (b) QoL assessed with the WHOQOL-BREF while taking measurement time, central sociodemographic, and health characteristics into account.

Results

During the COVID-19 pandemic, German adults mostly pursued problem- and meaning-focused coping factors and showed a relatively good QoL [Mean values (M) from 57.2 to 73.6, standard deviations (SD) = 16.3-22.6], except for the social domain (M = 57.2, SD = 22.6), and with a decreasing trend over time (β from -0.06 to -0.11, ps < 0.01). Whereas, escape-avoidance coping was negatively related to all QoL domains (β = -0.35, p < 0.001 for psychological, β = -0.22, p < 0.001 for physical, β = -0.13, p = 0.045 for social, β = -0.49, p < 0.001 for environmental QoL), support- and meaning-focused coping showed positive associations with various QoL domains (β from 0.19 to 0.45, ps < 0.01). The results also suggested differences in the pursuit of coping factors as well as in the strength of associations with QoL by sociodemographic characteristics. Escape-avoidance-focused coping was negatively associated with QoL levels in older and less educated adults (simple slopes differed at ps < 0.001), in particular.

Conclusions

The results demonstrated what types of coping may be helpful to avoid QoL deterioration (i.e., support- and meaning-focused coping) and provide implications for future universal or targeted health promotion (i.e., older or less educated adults who lack social or instrumental support) and preparedness in the face of unknown challenging societal situations similar to that of the COVID-19 pandemic. Cross-sectional trends of enhanced use of escape-avoidance-focused coping and QoL deterioration point toward a need for increased attention from public health and policy.

Effects of digital cognitive behavioral therapy for depression on suicidal thoughts and behavior: Protocol for a systematic review and meta-analysis of individual participant data

INTRODUCTION

Digital cognitive behavioral therapy (i-CBT) interventions for the treatment of depression have been extensively studied and shown to be effective in the reduction of depressive symptoms. However, little is known about their effects on suicidal thoughts and behaviors (STB). Information on the impact of digital interventions on STB are essential for patients' safety because most digital interventions are self-help interventions without direct support options in case of a suicidal crisis. Therefore, we aim to conduct a meta-analysis of individual participant data (IPDMA) to investigate the effects of i-CBT interventions for depression on STB and to explore potential effect moderators.

METHODS

Data will be retrieved from an established and annually updated IPD database of randomized controlled trials investigating the effectiveness of i-CBT interventions for depression in adults and adolescents. We will conduct a one-stage and a two-stage IPDMA on the effects of these interventions on STB. All types of control conditions are eligible. STB can be measured using specific scales (e.g., Beck scale suicide, BSS) or single items from depression scales (e.g., item 9 of the PHQ-9) or standardized clinical interviews. Multilevel linear regression will be used for specific scales, and multilevel logistic regression will be used for treatment response or deterioration, operationalized as a change in score by at least one quartile from baseline. Exploratory moderator analyses will be conducted at participant, study, and intervention level. Two independent reviewers will assess the risk of bias using the Cochrane Risk of Bias Tool 2.

CONCLUSION

This IPDMA will harness the available data to assess the effects (response and deterioration) of i-CBT interventions for depression interventions on STB. Information about changes in STB is essential to estimate patients' safety when engaging in digital treatment formats.

TRIAL REGISTRATION

We will pre-register this study with the open science framework after article acceptance to ensure consistency between online registration and the published trial protocol.

An Online Mindfulness Intervention for International Students: A Randomized Controlled Feasibility Trial

Background

Student mobility across borders poses challenges to health systems at the university and country levels. International students suffer from stress more than their local peers, however, do not seek help or underutilize existing help offers. Some barriers to help-seeking among international students are insufficient information regarding the health offers, stigma, and language, which might be overcome via culturally adapted internet and mobile-based interventions (IMI).

Method

A randomized controlled feasibility trial with a parallel design assessed the feasibility and potential efficacy of an online mindfulness intervention adapted for international university students. Participants were randomized into either an adapted online mindfulness intervention (StudiCareM-E) (IG, n = 20) or a waitlist control group (WL, n = 20). Participants were assessed at baseline (t0) and eight-week post-randomization (t1). The feasibility of StudiCareM-E was evaluated regarding intervention adherence, client satisfaction, and potential negative effects. The potential efficacy of StudiCareM-E was measured by means of the level of mindfulness, perceived stress, depression, anxiety, presenteeism, and wellbeing. Efficacy outcomes were evaluated with regression models on the intention-to-treat (ITT) sample (n = 40), adjusting for the baseline values.

Results

Participants' formative feedback suggested improvements in the content of the IMI. There were no crucial negative effects compared to WL. Assessment dropout was 35% (IG: 50%: WL: 20%), and intervention dropout was 60%. StudiCareM-E yielded significant improvements in mindfulness (β = .34), well-being (β = .37), and anxiety (β = -.42) compared to WL.

Conclusion

StudiCareM-E might be used among culturally diverse international student populations to improve their well-being. Future studies might carefully inspect the extent of the adaptation needs of their target group and design their interventions accordingly.

Exploring the usability of an internet-based intervention and its providing eHealth platform in an eye-tracking study

The proliferation of online eHealth has made it much easier for users to access healthcare services and interventions from the comfort of their own homes. This study looks at how well one such platform-eSano-performs in terms of user experience when delivering mindfulness interventions. In order to assess usability and user experience, several tools such as eye-tracking technology, think-aloud sessions, a system usability scale questionnaire, an application questionnaire, and post-experiment interviews were employed. Participants were evaluated while they accessed the first module of the mindfulness intervention provided by eSano to measure their interaction with the app, and their level of engagement, and to obtain feedback on both the intervention and its overall usability. The results revealed that although users generally rated their experience with the app positively in terms of overall satisfaction, according to data collected through the system usability scale questionnaire, participants rated the first module of the mindfulness intervention as below average. Additionally, eye-tracking data showed that some users skipped long text blocks in favor of answering questions quickly while others spent more than half their time reading them. Henceforth, recommendations were put forward to improve both the usability and persuasiveness of the app-such as incorporating shorter text blocks and more engaging interactive elements-in order to raise adherence rates. Overall findings from this study provide valuable insights into how users interact with the eSano's participant app which can be used as guidelines for the future development of more effective and user-friendly platforms. Moreover, considering these potential improvements will help foster more positive experiences that promote regular engagement with these types of apps; taking into account emotional states and needs that vary across different age groups and abilities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12652-023-04635-4.

Mediators of digital depression prevention in patients with chronic back pain: Findings from a multicenter randomized clinical trial

OBJECTIVE

The mechanisms of change in digital interventions for the prevention of depression are largely unknown. Here, we explored whether five theoretically derived intervening variables (i.e., pain intensity, pain-related disability, pain self-efficacy, quality of life [QoL], and work capacity) were mediating the effectiveness of a digital intervention specifically designed to prevent depression in patients with chronic back pain (CBP).

METHOD

This study is a secondary analysis of a pragmatic, observer-masked randomized clinical trial conducted at 82 orthopedic clinics in Germany. A total of 295 adults with a diagnosis of CBP and subclinical depressive symptoms were randomized to either the intervention group (n = 149) or treatment-as-usual (n = 146). Longitudinal mediation analyses were conducted with structural equation modeling and depression symptom severity as primary outcome (Patient Health Questionnaire-9 [PHQ-9]; 6 months after randomization) on an intention-to-treat basis.

RESULTS

Beside the effectiveness of the digital intervention in preventing depression, we found a significant causal mediation effect for QoL as measured with the complete scale of Assessment of Quality of Life (AQoL-6D; axb: -0.234), as well as for the QoL subscales mental health (axb: -0.282) and coping (axb: -0.249). All other potential intervening variables were not significant.

CONCLUSION

Our findings suggest a relevant role of QoL, including active coping, as change mechanism in the prevention of depression. Yet, more research is needed to extend and specify our knowledge on empirically supported processes in digital depression prevention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Three-Armed Randomized Controlled Trial to Evaluate the Effectiveness, Acceptance, and Negative Effects of StudiCare Mindfulness, an Internet- and Mobile-Based Intervention for College Students with No and "On Demand" Guidance

The college years can be accompanied by mental distress. Internet- and mobile-based interventions (IMIs) have the potential to improve mental health but adherence is problematic. Psychological guidance might promote adherence but is resource intensive. In this three-armed randomized controlled trial, "guidance on demand" (GoD) and unguided (UG) adherence-promoting versions of the seven-module IMI StudiCare Mindfulness were compared with a waitlist control group and each other. The GoD participants could ask for guidance as needed. A total of 387 students with moderate/low mindfulness were recruited. Follow-up assessments took place after 1 (t1), 2 (t2), and 6 (t3) months. Post-intervention (t2), both versions significantly improved the primary outcome of mindfulness (d = 0.91-1.06, 95% CI 0.66-1.32) and most other mental health outcomes (d = 0.25-0.69, 95% CI 0.00-0.94) compared with WL, with effects generally persisting after 6 months. Exploratory comparisons between UG and GoD were mostly non-significant. Adherence was low but significantly higher in GoD (39%) vs. UG (28%) at the 6-month follow-up. Across versions, 15% of participants experienced negative effects, which were mostly mild. Both versions effectively promoted mental health in college students. Overall, GoD was not associated with substantial gains in effectiveness or adherence compared with UG. Future studies should investigate persuasive design to improve adherence.

Help for insomnia from the app store? A standardized rating of mobile health applications claiming to target insomnia

A large number of mobile health applications claiming to target insomnia are available in commercial app stores. However, limited information on the quality of these mobile health applications exists. The present study aimed to systematically search the European Google Play and Apple App Store for mobile health applications targeting insomnia, and evaluate the quality, content, evidence base and potential therapeutic benefit. Eligible mobile health applications were evaluated by two independent reviewers using the Mobile Application Rating Scale-German, which ranges from 1 - inadequate to 5 - excellent. Of 2236 identified mobile health applications, 53 were included in this study. Most mobile health applications (68%) had a moderate overall quality. Concerning the four main subscales of the Mobile Application Rating Scale-German, functionality was rated highest (M = 4.01, SD = 0.52), followed by information quality (M = 3.49, SD = 0.72), aesthetics (M = 3.31, SD = 1.04) and engagement (M = 3.02, SD = 1.03). While scientific evidence was identified for 10 mobile health applications (19%), only one study employed a randomized controlled design. Fifty mobile health applications featured sleep hygiene/psychoeducation (94%), 27 cognitive therapy (51%), 26 relaxation methods (49%), 24 stimulus control (45%), 16 sleep restriction (30%) and 24 sleep diaries (45%). Mobile health applications may have the potential to improve the care of insomnia. Yet, data on the effectiveness of mobile health applications are scarce, and this study indicates a large variance in the quality of the mobile health applications. Thus, independent information platforms are needed to provide healthcare seekers and providers with reliable information on the quality and content of mobile health applications.

Posttraumatic stress disorder and diabetes-related outcomes in patients with type 1 diabetes

Mental comorbidities in patients with type 1 diabetes mellitus (T1D) are common, and can have a negative impact on acute blood glucose levels and long-term metabolic control. Information on the association of T1D and comorbid posttraumatic stress disorder (PTSD) with diabetes-related outcomes is limited. The aim was to examine the associations between a clinical diagnosis of PTSD and diabetes-related outcomes in patients with T1D. Patients with T1D and comorbid documented PTSD from the DPV database (n = 179) were compared to a group with T1D without PTSD (n = 895), and compared to a group with T1D without comorbid mental disorder (n = 895) by matching demographics (age, gender, duration of diabetes, therapy and migration background) 1:5. Clinical diabetes-related outcomes {body mass index (BMI), hemoglobin A1c (hbA1c), daily insulin dose, diabetic ketoacidosis (DKA), hypoglycemia, number of hospital admissions, number of hospital days} were analyzed, stratified by age groups (≤ 25 years vs. > 25 years). Patients with comorbid PTSD aged ≤ 25 years compared with patients without PTSD or patients without mental disorders had significantly higher HbA1c (8.71 vs. 8.30 or 8.24%), higher number of hospital admissions (0.94 vs. 0.44 or 0.32 per year) and higher rates of DKA (0.10 vs. 0.02 or 0.01 events/year). Patients with comorbid PTSD aged ≤ 25 years compared with patients without PTSD had significantly higher BMI (0.85 vs. 0.59) and longer hospital stays (15.89 vs.11.58 days) than patients without PTSD. Patients with PTSD > 25 years compared with patients without PTSD or without any mental comorbidities had significantly fewer hospital admissions (0.49 vs. 0.77 or 0.69), but a longer hospital length of stay (20.35 vs. 11.58 or 1.09 days). We found that PTSD in younger patients with T1D is significantly related to diabetes outcome. In adult patients with T1D, comorbid PTSD is associated with fewer, but longer hospitalizations. Awareness of PTSD in the care of patients with T1D should be raised and psychological intervention should be provided when necessary.

Using the Consolidated Framework for Implementation Research to evaluate a nationwide depression prevention project (ImplementIT) from the perspective of health care workers and implementers: Results on the implementation of digital interventions for farmers

Introduction

Depression has a significant impact on individuals and society, which is why preventive measures are important. Farmers represent an occupational group exposed to many risk factors for depression. The potential of guided, tailored internet-based interventions and a personalized telephone coaching is evaluated in a German project of the Social Insurance for Agriculture, Forestry and Horticulture (SVLFG). While user outcomes are promising, not much is known about actual routine care use and implementation of the two digital health interventions. This study evaluates the implementation from the perspective of social insurance employees to understand determinants influencing the uptake and implementation of digital interventions to prevent depression in farmers.

Methods

The data collection and analysis are based on the Consolidated Framework for Implementation Research (CFIR). Health care workers (n = 86) and implementers (n = 7) completed online surveys and/or participated in focus groups. The surveys consisted of validated questionnaires used in implementation research, adapted items from the CFIR guide or from other CFIR studies. In addition, we used reporting data to map implementation based on selected CFIR constructs.

Results

Within the five CFIR dimensions, many facilitating factors emerged in relation to intervention characteristics (e.g., relative advantage compared to existing services, evidence and quality) and the inner setting of the SVLFG (e.g., tension for change, compatibility with values and existing working processes). In addition, barriers to implementation were identified in relation to the outer setting (patient needs and resources), inner setting (e.g., available resources, access to knowledge and information) and characteristics of individuals (e.g., self-efficacy). With regard to the implementation process, facilitating factors (formal implementation leaders) as well as hindering factors (reflecting and evaluating) were identified.

Discussion

The findings shed light on the implementation of two digital prevention services in an agricultural setting. While both offerings seem to be widely accepted by health care workers, the results also point to revealed barriers and contribute to recommendations for further service implementation. For instance, special attention should be given to "patient needs and resources" by raising awareness of mental health issues among the target population as well as barriers regarding the inner setting.

Clinical Trial Registration

German Clinical Trial Registration: [DRKS00017078]. Registered on 18.04.2019.

Optimizing the predictive power of depression screenings using machine learning

Objective

Mental health self-report and clinician-rating scales with diagnoses defined by sum-score cut-offs are often used for depression screening. This study investigates whether machine learning (ML) can detect major depressive episodes (MDE) based on screening scales with higher accuracy than best-practice clinical sum-score approaches.

Methods

Primary data was obtained from two RCTs on the treatment of depression. Ground truth were DSM 5 MDE diagnoses based on structured clinical interviews (SCID) and PHQ-9 self-report, clinician-rated QIDS-16, and HAM-D-17 were predictors. ML models were trained using 10-fold cross-validation. Performance was compared against best-practice sum-score cut-offs. Primary outcome was the Area Under the Curve (AUC) of the Receiver Operating Characteristic curve. DeLong's test with bootstrapping was used to test for differences in AUC. Secondary outcomes were balanced accuracy, precision, recall, F1-score, and number needed to diagnose (NND).

Results

A total of k = 1030 diagnoses (no diagnosis: k = 775; MDE: k = 255) were included. ML models achieved an AUCQIDS-16 = 0.94, AUCHAM-D-17 = 0.88, and AUCPHQ-9 = 0.83 in the testing set. ML AUC was significantly higher than sum-score cut-offs for QIDS-16 and PHQ-9 (ps ≤ 0.01; HAM_D-17: p = 0.847). Applying optimal prediction thresholds, QIDS-16 classifier achieved clinically relevant improvements (Δbalanced accuracy = 8%, ΔF1-score = 14%, ΔNND = 21%). Differences for PHQ_9 and HAM-D-17 were marginal.

Conclusions

ML augmented depression screenings could potentially make a major contribution to improving MDE diagnosis depending on questionnaire (e.g., QIDS-16). Confirmatory studies are needed before ML enhanced screening can be implemented into routine care practice.

Prevalence and incidence of post-traumatic stress disorder and symptoms in people with chronic somatic diseases: A systematic review and meta-analysis

INTRODUCTION

Comprehensive evidence on prevalence and incidence of post-traumatic stress disorder (PTSD) and symptoms (PTSS) in people with chronic somatic diseases (CD) is lacking.

OBJECTIVE

To systematically and meta-analytically examine prevalence and incidence of PTSD and PTSS in people with CD compared with people without CD.

METHODS

MEDLINE, Embase, and PsycINFO were searched from inception (1946) to June 2020. Studies reporting point, 12-month, lifetime prevalence, or 12-month incidence of PTSD and PTSS in people with CD were selected and reviewed in accordance with PRISMA guidelines by two independent reviewers. Risk of bias was assessed by a combination of the Newcastle-Ottawa Scale and recommendations of the Cochrane Collaboration for non-comparative studies. Pooled estimates were calculated using random effects meta-analyses. Between-study heterogeneity was assessed using the I2 statistic.

RESULTS

Data were extracted from studies reporting on point prevalence (k = 60; n = 21,213), 12-month prevalence (k = 3; n = 913), and lifetime prevalence (k = 6; n = 826). 12-month incidence estimates were not available. The pooled estimate for the point prevalence of PTSD (k = 41) across CD was 12.7% (95% CI, 8.6 to 18.4%) and 19.6% regarding PTSS (13.2 to 28.1%; k = 24). Individuals with cerebrovascular disorder (k = 4) showed the highest pooled point prevalence for PTSD (23.6%, 95% CI, 16.8 to 32.0%), those with cardiovascular diseases the lowest (6.6%, 1.9 to 20.9%; k = 5). The pooled 12-month prevalence of PTSD (k = 3) was 8.8% (95% CI, 5.5 to 13.5%) and the lifetime prevalence (k = 6) was 12.1% (7.6 to 18.5%). Pooled estimates of PTSD prevalence in people with compared to those without CD showed an odds ratio of 9.96 (95% CI, 2.55 to 38.94; k = 5).

CONCLUSION

Post-traumatic stress disorder and PTSS are common and substantially higher in people with compared to those without CD. Earlier detection and treatment of this comorbidity might improve mental and physical health, reduce the incidence of further diseases, and reduce mortality.

CLINICAL TRIAL REGISTRATION

https://osf.io/9xvgz, identifier 9xvgz.

Barriers to and Facilitators of Engaging With and Adhering to Guided Internet-Based Interventions for Depression Prevention and Reduction of Pain-Related Disability in Green Professions: Mixed Methods Study

BACKGROUND

Internet-based interventions (IBIs) are effective for the prevention and treatment of mental disorders and are valuable additions for improving routine care. However, the uptake of and adherence to IBIs are often limited. To increase the actual use of IBIs, it is important to identify factors for engaging with and adhering to IBIs.

OBJECTIVE

We qualitatively evaluated barriers and facilitators regarding a portfolio of guided IBIs in green professions (farmers, gardeners, and foresters).

METHODS

Interview participants were selected from 2 randomized controlled trials for either the prevention of depression (Prevention of Depression in Agriculturists [PROD-A]) or the reduction of pain interference (Preventive Acceptance and Commitment Therapy for Chronic Pain in Agriculturists [PACT-A]) in green professions. The intervention group in PROD-A (N=180) participated in an IBI program, receiving access to 1 of 6 symptom-tailored IBIs. The intervention group in PACT-A (N=44) received access to an IBI for chronic pain. Overall, 41 semistructured qualitative interviews were conducted and transcribed verbatim. Barriers and facilitators were identified via inductive qualitative content analysis, with 2 independent coders reaching almost perfect intercoder reliability (Cohen κ=0.92). A quantitative follow-up survey (30/41, 73%) was conducted to validate the results. Subgroup analyses were performed based on intervention characteristics.

RESULTS

We identified 42 barriers and 26 facilitators, which we assigned to 4 superordinate categories related to the intervention (20 barriers; 17 facilitators), work (4 barriers; 1 facilitator), individual (13 barriers; 8 facilitators), and technical (5 barriers; 0 facilitators) aspects. Key barriers (identified by at least 50% of the interviewees) were time-consuming work life (29/40, 73%) and time-consuming private life (23/40, 58%). Similarly, the most frequently identified facilitators included presence of motivation, curiosity, interest and perseverance (30/40, 75%), flexible time management at work (25/40, 63%), and support from family and friends (20/40, 50%). Although agreement with barriers in the quantitative follow-up survey was rather low (mean 24%, SD 11%), agreement with facilitators was substantially higher (mean 80%, SD 13%). Differences in agreement rates were found particularly between intervention completers and noncompleters. Completers agreed significantly more often that perceived IBI success; being motivated, curious, interested, and perseverant; and having a persisting level of psychological strain have been facilitating. Noncompleters agreed more often with experiencing the e-coach contact as insufficient and technical problems as hindering for intervention completion.

CONCLUSIONS

Based on these results, strategies such as customization of modules for more flexible and adaptive use; video chat options with the e-coach; options to facilitate social support by family, friends, or other participants; or using prompts to facilitate training completion can be derived. These approaches could be evaluated in further quantitative research designs in terms of their potential to enhance intervention use in this occupational group.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00014000, https://tinyurl.com/3bukfr48; German Clinical Trials Register DRKS0001461, https://tinyurl.com/ebsn4sns.

Is Therapist Support Needed? Comparing Therapist- and Self-Guided Internet-Based CBT for Somatic Symptom Distress (iSOMA) in Emerging Adults

Persistent somatic symptoms of varying etiology are very common in emerging adults and can lead to distress and impairment. Internet-delivered interventions could help to prevent the burden and chronicity of persistent somatic symptoms. This study investigated the impact of therapist guidance on the effectiveness of a cognitive-behavioral Internet intervention for somatic symptom distress (iSOMA) in emerging adults, as a secondary analysis of a two-armed randomized controlled trial. We included 149 university students (83.2% female, 24.60 yrs) with varying degrees of somatic symptom distress who were either allocated to the 8-week intervention with regular, written therapeutic guidance (iSOMA guided) or to the control group (waitlist), which was afterwards crossed over to receive iSOMA with guidance-on-demand (iSOMA-GoD). Primary outcomes were somatic symptom distress (assessed by the PHQ-15) and psychobehavioral symptoms of the somatic symptom disorder (assessed by the SSD-12) at pre- and post-treatment. Secondary outcomes included depression, anxiety, and disability. Both treatments showed statistically significant pre-post improvements in primary (iSOMA-guided: d = 0.86-0.92, iSOMA-GoD: d = 0.55-0.63) and secondary outcomes. However, intention-to-treat analysis revealed non-significant between-group effects for all outcomes (ps ≥ .335), after controlling for confounding variables, and effect sizes were marginal (d = -0.06 to 0.12). Overall, our findings indicate that Internet-delivered cognitive behavioral therapy with regular guidance is not unequivocally superior to guidance-on-demand in alleviating somatic symptom distress and associated psychopathology in emerging adults. As a next step, non-inferiority studies are needed to test the robustness of these findings and their impact on clinical populations.

Lessons Learned from an Attempted Pragmatic Randomized Controlled Trial for Improvement of Chronic Pain-Associated Disability in Green Professions: Long-Term Effectiveness of a Guided Online-Based Acceptance and Commitment Therapy &nbsp;(PACT-A)

Musculoskeletal symptoms are increased in farmers, whereas the prevalence of chronified pain is unknown. Online interventions based on acceptance and commitment therapy (ACT) have shown encouraging results in the general population, representing a promising approach for reducing pain interference in green professions (i.e., farmers, foresters, gardeners). We conducted a pragmatic RCT comparing a guided ACT-based online intervention to enhanced treatment-as-usual in entrepreneurs, contributing spouses, family members and pensioners in green professions with chronic pain (CPG: ≥grade II, ≥6 months). Recruitment was terminated prematurely after 2.5 years at N = 89 (of planned N = 286). Assessments were conducted at 9 weeks (T1), 6 months (T2) and 12 months (T3) post-randomization. The primary outcome was pain interference (T1). The secondary outcomes encompassed pain-, health- and intervention-related variables. No treatment effect for reduction of pain interference was found at T1 (β = -0.16, 95%CI: -0.64-0.32, p = 0.256). Improvements in cognitive fusion, pain acceptance, anxiety, perceived stress and quality of life were found only at T3. Intervention satisfaction as well as therapeutic and technological alliances were moderate, and uptake and adherence were low. Results are restricted by low statistical power due to recruitment issues, high study attrition and low intervention adherence, standing in contrast to previous studies. Further research is warranted regarding the use of ACT-based online interventions for chronic pain in this occupational group. Trial registration: German Clinical Trial Registration: DRKS00014619. Registered: 16 April 2018.

Mobile Apps for the Management of Gastrointestinal Diseases: Systematic Search and Evaluation Within App Stores

Background

Gastrointestinal diseases are associated with substantial cost in health care. In times of the COVID-19 pandemic and further digitalization of gastrointestinal tract health care, mobile health apps could complement routine health care. Many gastrointestinal health care apps are already available in the app stores, but the quality, data protection, and reliability often remain unclear.

Objective

This systematic review aimed to evaluate the quality characteristics as well as the privacy and security measures of mobile health apps for the management of gastrointestinal diseases.

Methods

A web crawler systematically searched for mobile health apps with a focus on gastrointestinal diseases. The identified mobile health apps were evaluated using the Mobile Application Rating Scale (MARS). Furthermore, app characteristics, data protection, and security measures were collected. Classic user star rating was correlated with overall mobile health app quality.

Results

The overall quality of the mobile health apps (N=109) was moderate (mean 2.90, SD 0.52; on a scale ranging from 1 to 5). The quality of the subscales ranged from low (mean 1.89, SD 0.66) to good (mean 4.08, SD 0.57). The security of data transfer was ensured only by 11 (10.1%) mobile health apps. None of the mobile health apps had an evidence base. The user star rating did not correlate with the MARS overall score or with the individual subdimensions of the MARS (all P>.05).

Conclusions

Mobile health apps might have a positive impact on diagnosis, therapy, and patient guidance in gastroenterology in the future. We conclude that, to date, data security and proof of efficacy are not yet given in currently available mobile health apps.

Adult quality of life patterns and trajectories during the COVID-19 pandemic in Germany

Early investigations of subjective well-being responses to the COVID-19 pandemic indicated average deterioration but also high variability related to vulnerability of population groups and pandemic phase. Thus, we aimed to gain new insights into the characteristics of certain groups and their differences in subjective well-being response patterns over time. First, we performed Latent Class Analyses with baseline survey data of 2,137 adults (mean age = 40.98, SD = 13.62) derived from the German CORONA HEALTH APP Study to identify subgroups showing similarity of a comprehensive set of 50 risk and protective factors. Next, we investigated the course of quality of life (QoL) as an indicator of subjective well-being grouped by the identified latent classes from July 2020 to July 2021 based on monthly and pandemic phase averaged follow-up survey data by means of Linear Mixed-Effects Regression Modeling. We identified 4 latent classes with distinct indicators and QoL trajectories (resilient, recovering, delayed, chronic) similar to previous evidence on responses to stressful life events. About 2 out of 5 people showed a resilient (i.e., relative stability) or recovering pattern (i.e., approaching pre-pandemic levels) over time. Absence of depressive symptoms, distress, needs or unhealthy behaviors and presence of adaptive coping, openness, good family climate and positive social experience were indicative of a resilient response pattern during the COVID-19 pandemic. The presented results add knowledge on how to adapt and enhance preparedness to future pandemic situations or similar societal crises by promoting adaptive coping, positive thinking and solidary strategies or timely low-threshold support offers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-03628-4.

Digitale Phänotypisierung in der Psychologie – ein Quantensprung in der psychologischen Forschung?

Zusammenfassung. Digitale Phänotypisierung stellt einen neuen, leistungsstarken Ansatz zur Realisierung psychodiagnostischer Aufgaben in vielen Bereichen der Psychologie und Medizin dar. Die Grundidee besteht aus der Nutzung digitaler Spuren aus dem Alltag, um deren Vorhersagekraft für verschiedenste Anwendungsmöglichkeiten zu überprüfen und zu nutzen. Voraussetzungen für eine erfolgreiche Umsetzung sind elaborierte Smart Sensing Ansätze sowie Big Data-basierte Extraktions- (Data Mining) und Machine Learning-basierte Analyseverfahren. Erste empirische Studien verdeutlichen das hohe Potential, aber auch die forschungsmethodischen sowie ethischen und rechtlichen Herausforderungen, um über korrelative Zufallsbefunde hinaus belastbare Befunde zu gewinnen. Hierbei müssen rechtliche und ethische Richtlinien sicherstellen, dass die Erkenntnisse in einer für Einzelne und die Gesellschaft als Ganzes wünschenswerten Weise genutzt werden. Für die Psychologie als Lehr- und Forschungsdomäne bieten sich durch Digitale Phänotypisierung vielfältige Möglichkeiten, die zum einen eine gelebte Zusammenarbeit verschiedener Fachbereiche und zum anderen auch curriculare Erweiterungen erfordern. Die vorliegende narrative Übersicht bietet eine theoretische, nicht-technische Einführung in das Forschungsfeld der Digitalen Phänotypisierung, mit ersten empirischen Befunden sowie einer Diskussion der Möglichkeiten und Grenzen sowie notwendigen Handlungsfeldern.

ACTonDiabetes: study protocol of a pragmatic randomised controlled trial for the evaluation of an acceptance and commitment-based internet-based and mobile-based intervention for adults living with type 1 or type 2 diabetes

INTRODUCTION

Living with diabetes can be burdensome and lead to serious emotional distress and impaired mental health. Acceptance and commitment therapy (ACT) can support people facing the challenges of living with diabetes. This trial aims to evaluate the effectiveness and cost-effectiveness of the internet-based and mobile-based intervention (IMI) 'ACTonDiabetes' in reducing diabetes distress against enhanced treatment as usual (TAU+) following specialised diabetes care.

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted to evaluate the guided IMI ACTonDiabetes against TAU+. A total of 210 adults with type 1 or type 2 diabetes and elevated diabetes distress (Problem Areas in Diabetes ≥40) will be recruited at a specialised diabetes centre. The intervention begins 2-4 weeks after hospital discharge and takes about 7-10 weeks to complete. Assessments are performed at baseline and 5 and 10 weeks as well as 6 and 12 months after randomisation. The primary outcome is diabetes distress at a 10-week follow-up (T2). Secondary outcomes are depression (Patient Health Questionnaire-8), psychological well-being (WHO-5), quality of life (Assessment of Quality of Life-8 Dimension), Diabetes-related Self-Management Questionnaire, diabetes acceptance (Acceptance and Action Diabetes Questionnaire) and negative treatment effects (Inventory for the Assessment of Negative Effects of Psychotherapy). All statistical analyses will be performed based on the intention-to-treat principle with additional per-protocol analyses. Changes in outcomes will be evaluated using the general linear model. A health-economic evaluation will be conducted from a societal perspective. Reasons for drop-out will be systematically investigated.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the State Medical Chamber of Baden-Württemberg (file no. B-F-2019-010). Trial results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00016738.

Predictors of Dropout in a Digital Intervention for the Prevention and Treatment of Depression in Patients With Chronic Back Pain: Secondary Analysis of Two Randomized Controlled Trials

Background

Depression is a common comorbid condition in individuals with chronic back pain (CBP), leading to poorer treatment outcomes and increased medical complications. Digital interventions have demonstrated efficacy in the prevention and treatment of depression; however, high dropout rates are a major challenge, particularly in clinical settings.

Objective

This study aims to identify the predictors of dropout in a digital intervention for the treatment and prevention of depression in patients with comorbid CBP. We assessed which participant characteristics may be associated with dropout and whether intervention usage data could help improve the identification of individuals at risk of dropout early on in treatment.

Methods

Data were collected from 2 large-scale randomized controlled trials in which 253 patients with a diagnosis of CBP and major depressive disorder or subclinical depressive symptoms received a digital intervention for depression. In the first analysis, participants’ baseline characteristics were examined as potential predictors of dropout. In the second analysis, we assessed the extent to which dropout could be predicted from a combination of participants’ baseline characteristics and intervention usage variables following the completion of the first module. Dropout was defined as completing <6 modules. Analyses were conducted using logistic regression.

Results

From participants’ baseline characteristics, lower level of education (odds ratio [OR] 3.33, 95% CI 1.51-7.32) and both lower and higher age (a quadratic effect; age: OR 0.62, 95% CI 0.47-0.82, and age²: OR 1.55, 95% CI 1.18-2.04) were significantly associated with a higher risk of dropout. In the analysis that aimed to predict dropout following completion of the first module, lower and higher age (age: OR 0.60, 95% CI 0.42-0.85; age²: OR 1.59, 95% CI 1.13-2.23), medium versus high social support (OR 3.03, 95% CI 1.25-7.33), and a higher number of days to module completion (OR 1.05, 95% CI 1.02-1.08) predicted a higher risk of dropout, whereas a self-reported negative event in the previous week was associated with a lower risk of dropout (OR 0.24, 95% CI 0.08-0.69). A model that combined baseline characteristics and intervention usage data generated the most accurate predictions (area under the receiver operating curve [AUC]=0.72) and was significantly more accurate than models based on baseline characteristics only (AUC=0.70) or intervention usage data only (AUC=0.61). We found no significant influence of pain, disability, or depression severity on dropout.

Conclusions

Dropout can be predicted by participant baseline variables, and the inclusion of intervention usage variables may improve the prediction of dropout early on in treatment. Being able to identify individuals at high risk of dropout from digital health interventions could provide intervention developers and supporting clinicians with the ability to intervene early and prevent dropout from occurring.

Digital prevention of depression for farmers? A qualitative study on participants' experiences regarding determinants of acceptance and satisfaction with a tailored guided internet intervention program

INTRODUCTION

Farmers, forest workers and gardeners have a higher risk of developing depression compared to other occupational populations. As part of the German pilot project "With us in balance", the potential of six guided internet- and mobile-based interventions (IMIs) to prevent depression among their insurants is examined. The IMI program is tailored to various risk factors of depression, individual symptoms, and needs. Although IMIs have been shown to be effective in reducing depressive symptoms, there is little qualitative research about the acceptance of digital preventive IMIs. The aim of this qualitative study is to gain insights into participants' experiences with the guided IMIs by focusing on determinants for acceptance and satisfaction.

METHODS

Semi-structured interviews were conducted with 22/171 (13 %) intervention group (IG) participants of a randomized controlled trial. The interview guide was developed based on theoretical models of user acceptance (Unified Theory of Acceptance and Use of Technology) and patient satisfaction (evaluation model, discrepancy theory). The interviews were evaluated independently by two coders performing a deductive-inductive content analysis and attaining a substantial level of agreement (K = 0.73).

RESULTS

The qualitative analysis revealed 71 determinants for acceptance and satisfaction across ten dimensions: performance expectancy, organisation, e-coach, usability, training content and structure, training usage, training outcome, financing, social influence, and behavioural intention. The most frequently identified drivers for the IMI use include "location independence", "positive relationship to the e-coach" (each n = 19, 86 %), "personal e-coach guidance", "expertise of the e-coach", "target group specific adaptation" (each n = 18, 82 %), "flexibility", "high willingness for renewed participation" (each n = 17, 77 %), "fast and easy availability", "training of health enhancing attitudes and behaviours" and "content with figurative expressions" (each n = 16, 73 %).

DISCUSSION

The qualitative findings predominantly suggest the acceptance of and satisfaction with the IMI program for the prevention of depression in famers and related lines of work. Many identified positive drivers are related to the e-coach guidance, which emphasizes its importance in the preventive setting from the perspective of the participants. Nevertheless, some negative aspects have been identified which help to understand potential weaknesses of the IMI program. Participants indicated different needs in terms of IMI content and usage, which points towards the potential benefit of individualisation. The possibility of being able to use IMIs anonymously, flexibly and independently of location might be highly relevant for this specific target group.

Comparative effectiveness of three versions of a stepped care model for insomnia differing in the amount of therapist support in internet-delivered treatment: study protocol for a pragmatic cluster randomised controlled trial (GET Sleep)

INTRODUCTION

It is unclear how internet-delivered cognitive-behavioural therapy for insomnia (CBT-I) can be integrated into healthcare systems, and little is known about the optimal level of therapist guidance. The aim of this study is to investigate three different versions of a stepped care model for insomnia (IG1, IG2, IG3) versus treatment as usual (TAU). IG1, IG2 and IG3 rely on treatment by general practitioners (GPs) in the entry level and differ in the amount of guidance by e-coaches in internet-delivered CBT-I.

METHODS AND ANALYSIS

In this randomised controlled trial, 4268 patients meeting International Classification of Diseases, Tenth Revision (ICD-10) criteria for insomnia will be recruited. The study will use cluster randomisation of GPs with an allocation ratio of 3:3:3:1 (IG1, IG2, IG3, TAU). In step 1 of the stepped care model, GPs will deliver psychoeducational treatment; in step 2, an internet-delivered CBT-I programme will be used; in step 3, GPs will refer patients to specialised treatment. Outcomes will be collected at baseline, and 4 weeks, 12 weeks and 6 months after baseline assessment. The primary outcome is insomnia severity at 6 months. An economic evaluation will be conducted and qualitative interviews will be used to explore barriers and facilitators of the stepped care model.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Medical Centre-University of Freiburg. The results of the study will be published irrespective of the outcome.

TRIAL REGISTRATION NUMBER

DRKS00021503.