Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomised controlled trial.
ABSTRACT: BACKGROUND: Depression and anxiety are common, disabling and chronic. Self-guided internet-delivered treatments are popular, but few people complete them. New strategies are required to realise their potential. AIMS: To evaluate the effect of automated emails on the effectiveness, safety, and acceptability of a new automated transdiagnostic self-guided internet-delivered treatment, the Wellbeing Course, for people with depression and anxiety. METHOD: A randomised controlled trial was conducted through the website: www.ecentreclinic.org. Two hundred and fifty seven people with elevated symptoms were randomly allocated to the 8 week course either with or without automated emails, or to a waitlist control group. Primary outcome measures were the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7). RESULTS: Participants in the treatment groups had lower PHQ-9 and GAD-7 scores at post-treatment than controls. Automated emails increased rates of course completion (58% vs. 35%), and improved outcomes in a subsample with elevated symptoms. CONCLUSIONS: The new self-guided course was beneficial, and automated emails facilitated outcomes. Further attention to strategies that facilitate adherence, learning, and safety will help realise the potential of self-guided interventions. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.
Project description:BACKGROUND: A recent paper reported the outcomes of a study examining a new self-guided internet-delivered treatment, the Wellbeing Course, for symptoms of anxiety or depression. This study found the intervention resulted in significant symptom reductions. It also found that automated emails increased treatment completion and clinical improvements in a subsample with elevated anxiety and depression. AIMS: To examine the clinical outcomes and the effect of automated emails at 12 months post-treatment. METHOD: Participants, who were randomly allocated to a Treatment Plus Automated Emails Group (TEG; n = 100), a standard Treatment Group (TG; n = 106) or delayed-treatment Waitlist Control Group (Control; n = 51), were followed up at 12 months post-treatment. Eighty-one percent, 78% and 87% of participants in the TEG, TG and treated Waitlist Control Group provided symptom data at 12-month follow-up, respectively. The primary outcome measures were the Patient Health Questionnaire-9 Item Scale (PHQ-9) and the Generalized Anxiety Disorder-7 Item Scale (GAD-7). RESULTS: Significant improvements in symptoms of anxiety and depression were observed over time in both the TEG and TG (Fs >69, ps <.001) these were sustained from post-treatment to 12-month follow-up (ps >.05), and were associated with large effect sizes. No statistically significant differences in symptoms were found between the TEG and TG at post-treatment, 3-month or 12-month follow-up. Previously reported symptom differences between TEG and TG participants with comorbid symptoms were no longer present at 12-month follow-up (ps >.70). CONCLUSIONS: The overall benefits of the Wellbeing Course were sustained at 12-month follow-up. Although automated emails facilitated Course completion and reductions in symptoms for participants with comorbid anxiety and depression from pre-post treatment, these differences were no longer observed at 12-month follow-up. The results indicate that automated emails promote more rapid treatment response for people with elevated and comorbid symptoms, but may not improve longer term outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.
Project description:Background:Interest is growing in digital and telehealth delivery of mental health services, but data are scarce on outcomes in routine care. The federally funded Australian MindSpot Clinic provides online and telephone psychological assessment and treatment services to Australian adults. We aimed to summarise demographic characteristics and treatment outcomes of patients registered with MindSpot over the first 7 years of clinic operation. Methods:We used an observational design to review all patients who registered for assessment with the MindSpot Clinic between Jan 1, 2013, and Dec 31, 2019. We descriptively analysed the demographics, service preferences, and baseline symptoms of patients. Among patients enrolled in a digital treatment course, we evaluated scales of depression (Patient Health Questionnaire-9 [PHQ-9]) and anxiety (Generalized Anxiety Disorder 7-Item Scale [GAD-7]), as primary measures of treatment outcome, from the screening assessment to post-treatment and a 3 month follow-up. The Kessler Psychological Distress 10-Item Plus Scale was also used to assess changes in general distress and disability, and course satisfaction was measured post-treatment. Outcomes:A total of 121?652 screening assessments were started, of which 96?018 (78·9%) were completed. The mean age of patients was 35·7 years (SD 13·8) and 88?702 (72·9%) were women. Based on available assessment data, 36?866 (34·5%) of 106?811 participants had never previously spoken to a health professional about their symptoms, and most people self-reported symptoms of anxiety (88?879 [81·9%] of 108?494) or depression (78?803 [72·6%] of 108?494), either alone or in combination, at baseline. 21?745 patients started treatment in a therapist-guided online course, of whom 14?503 (66·7%) completed treatment (?four of five lessons). Key trends in service use included an increase in the proportion of people using MindSpot primarily for assessment and information, from 52·6% in 2013 to 66·7% in 2019, while the proportion primarily seeking online treatment decreased, from 42·6% in 2013 to 26·7% in 2019. Effect sizes and percentage changes were large for estimated mean scores on the PHQ-9 and GAD-7 from assessment to post-treatment (PHQ-9, Cohen's d effect size 1·40 [95% CI 1·37-1·43]; and GAD-7, 1·45 [1·42-1·47]) and the 3 month follow-up (PHQ-9, 1·36 [1·34-1·38]; and GAD-7, 1·42 [1·40-1·44]); proportions of patients with reliable symptom deterioration (score increase of ?6 points [PHQ-9] or ?5 points [GAD-7]) were low post-treatment (of 13?058 respondents, 184 [1·4%] had symptom deterioration on the PHQ-9 and 282 [2·2%] on the GAD-7); and patient satisfaction rates were high (12?452 [96·6%] of 12?895 respondents would recommend the course and 12?433 [96·7%] of 12?860 reported the course worthwhile). We also observed small improvements in disability following treatment as measured by days out of role. Interpretation:Our findings indicate improvement in psychological symptoms and positive reception among patients receiving online mental health treatment. These results support the addition of digital services such as MindSpot as a component in contemporary national mental health systems. Funding:None.
Project description:Background. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders. Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up. Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen's d = 0.77 (95% CI: 0.37-1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08-0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ(2)(N = 100, d f = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7. Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.
Project description:BACKGROUND:IntelliCare is a modular platform that includes 12 simple apps targeting specific psychological strategies for common mental health problems. OBJECTIVE:This study aimed to examine the effect of 2 methods of maintaining engagement with the IntelliCare platform, coaching, and receipt of weekly recommendations to try different apps on depression, anxiety, and app use. METHODS:A total of 301 participants with depression or anxiety were randomized to 1 of 4 treatments lasting 8 weeks and were followed for 6 months posttreatment. The trial used a 2X2 factorial design (coached vs self-guided treatment and weekly app recommendations vs no recommendations) to compare engagement metrics. RESULTS:The median time to last use of any app during treatment was 56 days (interquartile range 54-57), with 253 participants (84.0%, 253/301) continuing to use the apps over a median of 92 days posttreatment. Receipt of weekly recommendations resulted in a significantly higher number of app use sessions during treatment (overall median=216; P=.04) but only marginal effects for time to last use (P=.06) and number of app downloads (P=.08). Coaching resulted in significantly more app downloads (P<.001), but there were no significant effects for time to last download or number of app sessions (P=.36) or time to last download (P=.08). Participants showed significant reductions in the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) across all treatment arms (P s<.001). Coached treatment led to larger GAD-7 reductions than those observed for self-guided treatment (P=.03), but the effects for the PHQ-9 did not reach significance (P=.06). Significant interaction was observed between receiving recommendations and time for the PHQ-9 (P=.04), but there were no significant effects for GAD-7 (P=.58). CONCLUSIONS:IntelliCare produced strong engagement with apps across all treatment arms. Coaching was associated with stronger anxiety outcomes, and receipt of recommendations enhanced depression outcomes. TRIAL REGISTRATION:ClinicalTrials.gov NCT02801877; https://clinicaltrials.gov/ct2/show/NCT02801877.
Project description:Face-to-face mindfulness interventions have been shown to significantly decrease perceived stress, anxiety and depression and research is beginning to show similar benefits for such courses delivered via the internet. We investigated the feasibility and effectiveness of an online mindfulness course for perceived stress, anxiety and depression.A follow-up investigation of an online mindfulness course. Previous research examining the change in perceived stress showed promising results. Measures of anxiety and depression were added to the online mindfulness course and these were investigated as well as perceived stress using a new, larger sample.Participants (N=273) were self-referrals to the online course who completed the outcome measure immediately before the course, upon course completion and at 1 month follow-up.The programme consists of 10 sessions, guided meditation videos and automated emails, with elements of Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy, completed at a pace to suit the individual (minimum length 4 weeks).The Perceived Stress Scale, the Generalised Anxiety Disorder Assessment-7 and the Patient Health Questionnaire-9 (for depression). Mindfulness practice was self-reported at automated time points upon login, once the exercises and sessions for each week were completed.Perceived stress, anxiety and depression significantly decreased at course completion and further decreased at 1 month follow-up, with effect sizes comparable to those found with face-to-face and other online mindfulness courses and to other types of intervention, such as cognitive behavioural therapy for stress. The amount of meditation practice reported did affect outcome when controlling for baseline severity.The online mindfulness course appears to be an acceptable, accessible intervention which reduces stress, anxiety and depression. However, there is no control comparison and future research is required to assess the effects of the course for different samples.
Project description:BACKGROUND:Little is known about the burden of common mental disorders in Russia despite high levels of suicide and alcohol-related mortality. Here we investigated levels of symptoms, self-reports of ever having received a diagnosis and treatment of anxiety and depression in two Russian cities. METHODS:The study population was men and women aged 35-69?years old participating in cross-sectional population-based studies in the cities of Arkhangelsk and Novosibirsk (2015-18). Participants completed an interview which included the PHQ-9 and GAD-7 scales, questions on whether participants had ever received a diagnosis of depression or anxiety, and health service use in the past year. Participants also reported current medication use and medications were coded in line with the WHO anatomical therapeutic classification (ATC). Depression was defined as PHQ-9???10 and Anxiety as GAD-7???10. RESULTS:Age-standardised prevalence of PHQ-9???10 was 10.7% in women and 5.4% in men (GAD-7???10 6.2% in women; 3.0% in men). Among those with PHQ-9???10 17% reported ever having been diagnosed with depression (equivalent finding for anxiety 29%). Only 1.5% of those with PHQ-9???10 reported using anti-depressants and 0.6% of those with GAD-7???10 reported using anxiolytics. No men with PHQ-9???10 and/or GAD-7???10 reported use of anti-depressants or anxiolytics. Use of health services increased with increasing severity of both depression and anxiety. CONCLUSION:There was a large gap between symptoms and reporting of past diagnosis and treatment of common mental disorders in two Russian cities. Interventions aimed at improving mental health literacy and reducing stigma could be of benefit in closing this substantial treatment gap.
Project description:BACKGROUND:Depression and anxiety symptoms are prevalent among university students in both developed and developing settings. Recently, grit, defined as perseverance and passion for long-term goals, has emerged as an indicator of success and well-being. However, the relationship between grit and poor mental health outcomes among university students is largely unknown. The current study investigates the relationship of grit with depression and anxiety among university students in Chiang Mai, Thailand. METHODS:This cross-sectional study was conducted from January to March 2018 among university students aged 18-24 years from Chiang Mai University, the first largest university in Chiang Mai Province. Depression and anxiety were assessed with the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) Scales, respectively. Grit was measured using the 8-item Short Grit Scale (GRIT-S). Grit scores were grouped into three categories: low (below the 25th percentile); average (from the 25th to the 75th percentiles); and high (above the 75th percentile). The other covariates included variables such self-esteem and socio-demographic variables. RESULTS:Of the 800 participants included in the study, 405 (50.6%) were female and 395 (49.4%) were male. Respectively 21.4% and 7.8% of the participants had depression and clinical symptoms of GAD. Increasing levels of grit negatively correlated with PHQ-9 and GAD-7 scores. Participants with high level of grit scored respectively 1.69 points (P <0.001) and 1.71 points (P < 0.001) lower on the PHQ-9 scale and GAD-7 scores. Similarly, self-esteem was negatively associated with PHQ-9 and GAD-7 scores. CONCLUSION:Our findings highlight the negative correlation of grit with poor mental health outcomes, particularly depression and anxiety. Interventions designed to improve grit could play an essential role in the prevention of adverse mental health outcomes among university students.
Project description:BACKGROUND:Internet-based cognitive behavior therapy (iCBT) interventions have the potential to help individuals with depression, regardless of time and location. Yet, limited information exists on the longer-term (>6 months) effects of iCBT and adherence to these interventions. OBJECTIVE:The primary aim of this study was to evaluate the longitudinal (12 months) effectiveness of a fully automated, self-guided iCBT intervention called Thrive, designed to enhance engagement with a rural population of adults with depression symptoms. The secondary aim was to determine whether the program adherence enhanced the effectiveness of the Thrive intervention. METHODS:We analyzed data from 181 adults who used the Thrive intervention. Using self-reports, participants were evaluated at baseline, 8 weeks, 6 months, and 12 months for the primary outcome of depression symptom severity using the Patient Health Questionnaire-9 (PHQ-9) scale and secondary outcome measures, namely, the Generalized Anxiety Disorder Scale-7 (GAD-7) scores, Work and Social Adjustment Scale (WSAS) scores, Conner-Davidson Resilience Scale-10 (CD-RISC-10) scores, and suicidal ideation (ninth item of the PHQ-9 scale) scores. The Thrive program adherence was measured using the numbers of program logins, page views, and lessons completed. RESULTS:The assessment response rates for 8-week, 6-month, and 12-month outcomes were 58.6% (106/181), 50.3% (91/181), and 51.4% (93/181), respectively. By 8 weeks, significant improvements were observed for all outcome measures. These improvements were maintained at 12 months with mean reductions in severities of depression (mean -6.5; P<.001) and anxiety symptoms (mean -4.3; P<.001). Improvements were also observed in work and social functioning (mean -6.9; P<.001) and resilience (mean 4.3; P<.001). Marked decreases were observed in suicidal ideation (PHQ-9 ninth item score >1) at 6 months (16.5%) and 12 months (17.2%) compared to baseline (39.8%) (P<.001). In regard to the program adherence, cumulative counts of page views and lessons completed were significantly related to lower PHQ-9, GAD-7, and WSAS scores and higher CD-RISC-10 scores (all P values <.001 with an exception of page views with WSAS for which P value was .02). CONCLUSIONS:The Thrive intervention was effective at reducing depression and anxiety symptom severity and improving functioning and resilience among a population of adults from mostly rural communities in the United States. These gains were maintained at 1 year. Program adherence, measured by the number of logins and lessons completed, indicates that users who engage more with the program benefit more from the intervention. TRIAL REGISTRATION:ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878.
Project description:BACKGROUND:Depression is twice as common in diabetes mellitus (DM) as the general population and is associated with adverse health outcomes, but access to evidence-based therapies such as cognitive behavioral therapy (CBT) is limited in routine diabetes care. Past research has shown that generic Internet-based cognitive behavioral therapy (iCBT) is an effective treatment for depression in the general population, but it has never been evaluated in people with comorbid depression and DM. OBJECTIVE:The aim of our study was to examine the efficacy of a generic 6-lesson iCBT delivered over 10 weeks in people with major depressive disorder (MDD) and DM. METHODS:Participants with comorbid MDD and DM (type 1 or 2) were recruited online and randomized to an iCBT program with therapist support provided by phone and email (n=42) or a treatment as usual (TAU, n=49) control group. Outcomes were assessed through Web-based self-report questionnaires and the trial was Web-based with no face-to-face components. Primary outcomes were self-reported depression (patient health questionnaire-9, PHQ-9), diabetes-related distress (problem areas in diabetes, PAID), and self-reported glycemic control (hemoglobin A1c, HbA1c). Secondary outcomes were general distress (Kessler 10-item psychological distress scale, K-10) and disability (short form 12-item, SF-12), generalized anxiety (generalized anxiety disorder 7-item, GAD-7), and somatization (PHQ-15). The iCBT group was assessed at 3 months. RESULTS:A total of 27 participants (66%; 27/41) completed the iCBT program. Analyses indicated between-group superiority of iCBT over TAU at posttreatment on PHQ-9 (g=0.78), PAID (g=0.80), K-10 (g=1.06), GAD-7 (g=0.72), and SF-12 mental well-being scores (g=0.66), but no significant differences in self-reported HbA1c levels (g=0.14), SF-12 physical well-being, or PHQ-15 scores (g=0.03-0.21). Gains were maintained at 3-month follow-up in the iCBT group, and the 87% (27/31) of iCBT participants who were interviewed no longer met criteria for MDD. Clinically significant change following iCBT on PHQ-9 scores was 51% (21/41) versus 18% (9/49) in TAU. CONCLUSIONS:iCBT for depression is an efficacious, accessible treatment option for people with diabetes. Future studies should explore whether tailoring of iCBT programs improves acceptability and adherence, and evaluate the long-term outcomes following iCBT. TRIAL REGISTRATION:Australian and New Zealand Clinical Trials Registry (ACTRN): 12613001198718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365208&isReview=true (Archived by WebCite at http://www.webcitation.org/6qCR8Fi9V).
Project description:Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety.The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety.This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann-Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status.Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P<.001), GAD-7 (P=.002), and CSE (P<.001) questionnaire scores. A strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572, P=.001, n=28) was observed. The mixed-effects repeated-measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (P<.001), GAD-7 (P=.007), and CSE (P=.001).This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.