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

BACKGROUND: Depression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention. OBJECTIVE: This systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life. METHODS: The Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October). RESULTS: The search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] -0.43, 95% CI -0.67 to -0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001). CONCLUSIONS: This systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements.

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

BACKGROUND: Depression is a worldwide disease. CBT-based self-help treatment allows patients with mild to moderate depression symptoms to improve their depression or to bridge the waiting- or pandemic period until they receive further clinical treatment. OBJECTIVE: This systematic review and meta-analysis aims to explore the efficacy, acceptability and improvement in quality of life of computer-delivered and/or internet-based CBT self-help interventions with minimal guidance (up to 10 min) for depression. The second aim was to compare the effectiveness of reducing depression symptoms at post-treatment of treatment by the type of minimal guidance: (1) e-mail, (2) telephone calls, (3) e-mail and telephone together, or (4) face-to-face. METHODS: The Cochrane depression, anxiety, and neurosis review group's specialized register electronic searches, grey literature, reference lists and correspondence were used to search for published and unpublished RCTs that reported efficacy of computer- and/or internet-based CBT self-help treatments for depression with minimal guidance up to 10 min per week. Methodological quality of included studies was evaluated with Cochrane Collaboration tools for assessing risk of bias. The meta-analysis was accomplished using the RevMen software. RESULTS: In total, 2809 study abstracts were checked for eligibility. Out of these, 19 studies (21 samples) with a total of 3226 participants were included. The results showed that concerning efficacy, the treatment group is superior to the control group with a medium to large effect size of 0.65. Also, treatment groups with combined guidance by e-mail and telephone calls together had greater effects (SMD -0.76) than groups with other types of minimal guidance (guided by e-mail SMD -0.63; guided face to-face SMD - 0.66; guided by telephone calls SMD -0.49). Findings showed also, that iCBT with minimal guidance had small but statistically significant effect size of 0.28 in improving quality of life. Moreover, there were higher drop-out rates in the treatment condition (RR 1.36) than in the control groups. CONCLUSIONS: The results of this meta-analysis support the efficacy of computer- and/or internet-based CBT self-help programs with minimal weekly guidance up to only 10 min for improving depression symptoms at post-treatment for adults. In addition, the results are pointing towards two practical implications. Firstly, depressed persons can use self-help treatment with minimal guidance at home to improve their symptoms or to bridge the waiting time - or pandemic period - before they receive professional face-to-face treatment. Secondly, it can help clinicians to make the decision about using CBT-based self-help treatments for patients that do not need urgent professional treatment, or to combine it with face-to-face therapy.

[Screening Instruments for the Detection of Male-Specific Symptoms of Unipolar Depression - A Critical Overview]. / Screeninginstrumente zur Erfassung von männerspezifischen Symptomen der unipolaren Depression ­ Ein kritischer Überblick.

BACKGROUND: Epidemiological studies have repeatedly pointed out gender differences in unipolar depression, whereas women have a 1.5 to 3 times higher risk of receiving a diagnosis. This however stands in sharp contrast with the 10 times higher suicide-rate of men, although depression is among the main risk-factors for suicide. Current literature therefore suspects an under-diagnosis of depression in men which is yet to be explained. While there is a vast body of literature covering the influence of gender norms, different symptomatology and use of health care services of men and women, systematic examinations of the role of diagnostic inventories or screening-instruments are currently not available. METHOD: A systematic literature search was conducted in order to provide an overview of current male-specific instruments for the detection of depression and to point out research gaps in the field of depression in men. RESULTS: Gender-specific inventories were used in 8 out of 122 relevant titles. Differences in the prevalence of unipolar depression tend to diminish or even disappear when gender-specific inventories are being used. DISCUSSION: Existing male-specific screening-instruments have only partly been validated and gender-specific instruments specifically designed for the detection of depression in primary care are currently lacking.

[From the First Symptoms of Depression to Treatment. When and Where are People Seeking Help? Does Stigma Play a Role? - Results from a Survey at a German Convention for People with Depression]. / Von den ersten Symptomen bis zur Behandlung einer Depression. Wann und bei wem suchen Menschen mit Depression Hilfe? Welche Rolle spielt Stigmatisierung?

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

Understanding Patient Experience Using Internet-based Email Surveys: A Feasibility Study at Mount Sinai Hospital.

Email is becoming a widely accepted communication tool in healthcare settings. This study sought to test the feasibility of Internet-based email surveys of patient experience in the ambulatory setting. We conducted a study of email Internet-based surveys sent to patients in selected ambulatory clinics at Mount Sinai Hospital in Toronto, Canada. Our findings suggest that email links to Internet surveys are a feasible, timely and efficient method to solicit patient feedback about their experience. Further research is required to optimally leverage Internet-based email surveys as a tool to better understand the patient experience.

Personal and perceived stigmatization of depression: a comparison of data from the general population, participants of a depression congress and job placement officers in Germany.

Personal and perceived depression stigma was assessed with Griffiths and colleagues׳ Depression Stigma Scale in 1509 German adults. The sample comprised three groups of participants: attendees of a depression congress, job placement officers and a representative general population sample. In all groups, personal stigma was lower than perceived stigma. Personal stigma was significantly higher in the general population than in the placement officers, and lowest in congress attendees. Perceived stigma was lower in congress attendees than in the general population. Personal stigma was lower in women decreased with age. The finding of lower personal stigma compared to perceived stigma might reflect effects of social desirability. Those with less contact with persons with depression, i.e. job placement officers and the general population, may be less tolerant and lack understanding of depression, resulting in higher levels of personal stigma. These findings support the notion that depression campaigns should be tailor-made to address gender and age-specific differences in personal and perceived stigma.

Effects of angular shift transformations between movements and their visual feedback on coordination in unimanual circling.

Tool actions are characterized by a transformation between movements and their resulting consequences in the environment. This transformation has to be taken into account when tool actions are planned and executed. We investigated how angular shift transformations between circling movements and their visual feedback affect the coordination of this feedback with visual events in the environment. We used a task that required participants to coordinate the visual feedback of a circular hand movement (presented on the right side of a screen) with a circling stimulus (presented on the left side of a screen). Four stimulus-visual feedback relations were instructed: same or different rotations of stimulus and visual feedback, either in same or different y-directions. Visual speed was varied in three levels (0.8, 1, and 1.2 Hz). The movement-visual feedback relation was manipulated using eight angular shifts: (-180, -135, -90, -45, 0, 45, 90, and 135°). Participants were not able to perform the different rotation/different y-direction pattern, but instead fell into the different rotation/same y-direction pattern. The different rotation/same y-direction pattern and the same rotation/same y-direction pattern were performed equally well, performance was worse in the same rotation/different y-direction pattern. Best performance was observed with angular shifts 0 and -45° and performance declined with larger angular shifts. Further, performance was better with negative angular shifts than with positive angular shifts. Participants did not fully take the angular shift transformation into account: when the angular shifts were negative the visual feedback was more in advance, and when angular shifts were positive the visual feedback was less in advance of the stimulus than in 0° angular shift. In conclusion, the presence and the magnitude of angular shift transformations affect performance. Internal models do not fully take the shift transformation into account.

Mount Sinai Hospital's approach to Ontario's Health System Funding Reform.

In April 2012, the Ontario government introduced Health System Funding Reform (HSFR), a transformational shift in how hospitals are funded. Mount Sinai Hospital recognized that moving from global funding to a "patient-based" model would have substantial operational and clinical implications. Adjusting to the new funding environment was set as a top corporate priority, serving as the strategic basis for re-examining and redesigning operations to further improve both quality and efficiency. Two years into HSFR, this article outlines Mount Sinai Hospital's approach and highlights key lessons learned.

Effects of angular gain transformations between movement and visual feedback on coordination performance in unimanual circling.

Tool actions are characterized by a transformation (of spatio-temporal and/or force-related characteristics) between movements and their resulting consequences in the environment. This transformation has to be taken into account, when planning and executing movements and its existence may affect performance. In the present study we investigated how angular gain transformations between movement and visual feedback during circling movements affect coordination performance. Participants coordinated the visual feedback (feedback dot) with a continuously circling stimulus (stimulus dot) on a computer screen in order to produce mirror symmetric trajectories of them. The movement angle was multiplied by a gain factor (0.5-2; nine levels) before it was presented on the screen. Thus, the angular gain transformations changed the spatio-temporal relationship between the movement and its feedback in visual space, and resulted in a non-constant mapping of movement to feedback positions. Coordination performance was best with gain = 1. With high gains the feedback dot was in lead of the stimulus dot, with small gains it lagged behind. Anchoring (reduced movement variability) occurred when the two trajectories were close to each other. Awareness of the transformation depended on the deviation of the gain from 1. In conclusion, the size of an angular gain transformation as well as its mere presence influence performance in a situation in which the mapping of movement positions to visual feedback positions is not constant. When designing machines or tools that involve transformations between movements and their external consequences, one should be aware that the mere presence of angular gains may result in performance decrements and that there can be flaws in the representation of the transformation.

Mental health treatment seeking among patients with OCD: impact of age of onset.

BACKGROUND: Several studies have described the deficits in the health care provided to persons with obsessive-compulsive disorder (OCD), however, without making any distinction between psychiatric-psychotherapeutic professionals and general practitioners or other professionals. Also, the relation between subjectively defined early signs of the disorder, diagnosis and utilization of professional help has not yet been investigated systematically. The present study addresses these questions, using a self-rating questionnaire for patients with OCD (questionnaire on the utilization of professional help by patients with OCD). METHODS: Eighty-eight patients with OCD, who came to our University Hospital Outpatient Clinic for obsessive-compulsive disorders in Leipzig, participated in the study. The questionnaire, which had been developed specially for this survey, asked study participants to remember when they had first perceived signs of their disorder and their first-time utilization of professional help. RESULTS: Patients with OCD and early onset of disorder sought professional help later than did patients with later onset of disorder. When professional help was utilized, it took 2 years on average before the diagnosis was made. Patients with OCD first consulted a psychiatrist or psychotherapist and not the general practitioner as their first professional contact person. CONCLUSION: First signs in the early stages of OCD, particularly with an onset in childhood and adolescence have to be diagnosed at an earlier stage for appropriate treatment. Psychiatrists and psychotherapists, not primarily general practitioners, have a particularly high demand for further education about early diagnosis and treatment of OCD.

[Mental health in the working world from the perspective of occupational physicians]. / Psychische Gesundheit in der Arbeitswelt aus der Sicht von Betriebs- und Werksärzten.

OBJECTIVE: As a contact person for mental health problems, occupational physicians have a wide range of tasks including the assessment and adaption of company-related psychosocial conditions and the implementation of treatment and rehabilitation measures. It is of interest how they perceive the relevance and occurrence of mental disorders on one hand, and the prevention and treatment of employees' mental disorders within the company on the other. METHOD: Data collection with paper-and-pencil and Internet survey. Statistical analysis was performed with PASW. RESULTS: The majority said that sickness absence and occupational invalidity due to mental disorders have increased in the past years. 65.4 % of the company physicians said that their company has not implemented any prevention programmes. About one third said that mental disorders are handled differently in comparison to physical disorders (insecurity, concealment and social exclusion of the persons affected). Information and education of the company's management are of great importance. CONCLUSION: There is need for action when it comes to the qualification and further education of occupational physicians and the implementation of prevention programmes.

Vision-to-event and movement-to-event coordination in an unimanual circling task.

Coordination of actions with events in extracorporeal space is essential for many everyday tasks. In the present study, we investigated how transformations, like in tool use, and varying the spatial context affect action coordination. For this aim, we used a circling task that required participants to coordinate the visual feedback of hand movements with a clockwise circling stimulus (event). The trajectories of stimulus and visual feedback were presented horizontally aligned (group horizontal), within each other (group interleaved) or vertically aligned (group vertical). Within groups, we varied the instructed rotation direction of stimulus and visual feedback (same and different), and y-direction of visual feedback relative to the stimulus (same and different). To dissociate movements and the associated proprioceptive/kinesthetic feedback from visual movement feedback, participants performed the tasks under regular and transformed visual feedback (180° angular shift). Results indicated that action coordination follows the principle of vision-to-event coordination (similar data patterns with regular and transformed feedback), but subtle effects of movement-to-event coordination were also observed (larger difference in performance between same y-direction and different y-direction conditions with regular than with transformed feedback). The presence of a transformation affected performance negatively. The different visual layouts affected the different conditions differentially, pointing to the importance of the visual context. In conclusion, vision-to-event coordination dominates unimanual action coordination. The quality of performance is influenced by perceptual processes based on differential processing of the horizontal and vertical axis, and based on Gestalt principles.

Depression in the workplace: a systematic review of evidence-based prevention strategies.

BACKGROUND: Depression is one of the most common mental disorders, causing enormous personal and economic burden. In its early stages, however, it is the most manageable of mental disorders. The workplace, where a large proportion of the adult population can be reached, might be a good setting for prevention interventions that target depression directly. AIMS: Identify evidence-based indicated/secondary prevention strategies for depression in the workplace. METHODS: Systematic review of articles published until February 2010 using PubMed, EbscoHost and the Cochrane Library. Studies were selected based on different inclusion criteria, such as diagnosis of depression with validated screening instruments and presence of a control group. RESULTS: A total of 9,173 articles were found. One evaluated intervention study in the workplace met all inclusion criteria (French APRAND programme). The intervention, which combined the provision of diagnosis and psychoeducation, had a positive effect on people with depression, with a significant trend towards chances of recovery or remission after 1 year. The remaining studies did not meet the predefined inclusion criteria of this systematic review. CONCLUSION: The findings are quite sobering given the high prevalence of depression and the individual and societal burden caused by it. More tailor-made interventions in the workplace targeting depression directly are needed.

Impact of a campaign on the public's attitudes towards depression.

A public campaign was launched in 2000 as part of the four-level community-based intervention 'Nuremberg Alliance Against Depression' (NAD) in Nuremberg, Germany. Evaluation results will be presented. A baseline survey was done before the campaign in Nuremberg and Wuerzburg (control region), two surveys followed 10 and 22 months after the implementation. Multiple regression analyses were performed, with time, place and the interaction of time and location as independent and the corresponding items as dependent variables. For the general population, the campaign was successful in creating awareness for the NAD. For persons who reported experience with depression and persons aware of the NAD, analyses showed positive desirable effects: more awareness of depression and the NAD. In addition, among those aware, more positive attitudes towards medication treatment and antidepressants developed and also 'lack of self-discipline' declined as causal explanation as did the notion 'pull yourself together' as treatment option. The campaign induced relevant changes mainly in persons aware of the NAD and persons who reported to have had experience with depression. The fact that many of the changes in the general population declined in the second year of the campaign, when activities were done with lower intensity, illustrates the need for permanent depression awareness action.

Collaboration to partnerships.

Partnerships are at the center of the Hospital of the University of Pennsylvania Nursing Excellence Professional Practice (HUP-NEPP) model. Through the use of collaboration, skilled communication, and respectful workplace, partnerships can be formed, leading ultimately to world-class patient care. At HUP, interdisciplinary partnerships are evidenced by the clinical nurses through shared governance. This article describes the components necessary to form successful partnerships.

[Evaluation of target-group oriented interventions aimed at reducing the stigma surrounding mental illness]. / Evaluation zielgruppenorientierter Interventionen zur Reduzierung des Stigmas psychischer Krankheit.

OBJECTIVE: To provide a systematic review of target-group oriented interventions aimed at reducing the stigma surrounding mental illness. METHODS: An electronic literature search was carried out based on PubMed. In addition, the reference lists of included studies were examined and other sources like the internet were used. RESULTS: 51 studies could be identified, over half of them being targeted at school students. There was a large variation in the format of the various interventions. One half of interventions were based exclusively on education, the other half on a combination of education with contact with someone with a mental disorder. The vast majority of studies reported positive intervention effects. However, in several studies the effect did not persist over a time period of a few months. It appears easier to improve knowledge or to change misconceptions of mental disorders than to reduce the tendency to distance oneself from people with mental illness. When directly comparing the effect of interventions based exclusively on education with those combining education with facilitating contact with people with mental disorders, the latter proved more effective. CONCLUSION: A remarkable number of targeted interventions aimed at reducing the stigma attached to mental illness have been carried out. However, due to methodological limitations no definite assessment of the effect of these interventions is possible at the present time. There is a pressing need for research that adheres more closely to the methodological standards of evaluation research.

Adverse parenting as a risk factor in the occurrence of anxiety disorders : a study in six European countries.

OBJECTIVE: The aim of the study was to test the homogeneity of the association between adverse parenting and anxiety disorders within these disorders as well as among six European countries. METHOD: Based on data from 8,232 respondents (part II sample) originating from the European study of the epidemiology of mental disorders (ESEMeD), we examined the association between three dimensions of parental rearing (care, overprotection, authoritarianism) measured by a short form of the parental bonding instrument (PBI) and anxiety disorders by computing one logistic regression model per disorder. RESULTS: A similar pattern of recalled parenting behaviour across the four anxiety disorders assessed was found, with care and overprotection having the strongest associations. There were only minor country-specific variations of this pattern. CONCLUSION: Our results suggest an association between adverse parenting and the risk of anxiety disorders in particular as well as psychiatric disorders in general that is rather non-disorder specific.

[Social psychiatry in the field of contrasting context between psychiatry and Social Medicine]. / Sozialpsychiatrische Forschung im Spannungsfeld zwischen Psychiatrie und Sozialmedizin.

OBJECTIVE: There has been a discussion going on that Social Psychiatry has entered a state of crisis in terms of its socio-scientific roots. Little is known, however, about its relationship to Social Medicine. The question is whether Social Psychiatry, having grown apart from Sociology, has also lost its scientific relation to Social Medicine. METHOD: A systematic literature analysis of all works published in "Psychiatrische Praxis" - PP and "Das Gesundheitswesen"--GHW in the years 2004/2005 was done. All works concerning Social Psychiatry were analysed. The same procedure was applied to all abstracts, posters and presentations for the annual meetings of the German Society of Social Medicine and Prevention (DGSMP). RESULTS: 10 % off all articles published in GHW and 97 % in PP address issues of Social Psychiatry. Apart from similarities in terms of their theoretical, practical and institutional background and the research methods applied, there are a number of differences. CONCLUSIONS: Social Psychiatry has not lost its scientific relation to Social Medicine, however, the scientific cooperation between the two needs to be intensified.

Burnout of caregivers: a comparison between partners of psychiatric patients and nurses.

Care of a person with mental illness involves multiple burdens, possibly leading to burnout. This study compares partners of persons with schizophrenia and depression with nursing staff based on dimensions of burnout. Nursing staff and partners of patients with schizophrenia or depression were consecutively recruited from psychiatric hospitals and interviewed with the Maslach Burnout Inventory. No significant differences were found in the three dimensions of burnout (emotional exhaustion, depersonalization, and personal accomplishment) for the two groups of caregivers. About one fourth of the respondents in both groups showed a high degree of burnout. Professional and nonprofessional caregivers face a similar degree of burden and need support to perform their caretaking tasks.

The relationship between biogenetic causal explanations and social distance toward people with mental disorders: results from a population survey in Germany.

AIMS: Several studies have found an inverse relationship between people's readiness to endorse biogenetic causal explanations of mental disorder and their desire for social distance from people with mental disorders. The aim of this study is to examine why this may be the case. METHOD: In the spring of 2001, a population survey was carried out among German citizens aged 18 years and older, living in private households. A total of 5025 interviews were conducted, reflecting a response rate of 65.1%. At the beginning of the personal, fully structured interview, respondents were presented with a vignette containing a diagnostically unlabelled psychiatric case history, either depicting a case of schizophrenia or major depressive disorder. Using five-point Likert scales, causal attributions as well as perceived dangerousness, fear and the desire for social distance were assessed. RESULTS: The more respondents endorse a brain disease as a cause, the more dangerous they believe the person with schizophrenia or major depression to be. Respondents who perceive the individual in the vignette as being dangerous express a higher degree of fear and a greater preference for social distance from these individuals. As compared with brain disease, the relationships between heredity and perceived dangerousness are less pronounced for both disorders. CONCLUSIONS: Our analysis showed that endorsing biogenetic explanations decreases the likelihood of social acceptance of people with schizophrenia and major depression. Rejecting behavioural responses in the form of social distance desired from people with schizophrenia and major depression result from cognitive emotional processes in which biogenetic causal attributions are linked to lack of self-control, unpredictability and dangerousness, which, in turn, are associated with fear of these people.