Uptake of a self-guided digital treatment for depression and anxiety: A qualitative study exploring patient perspectives and decision-making.

BACKGROUND: Despite the demonstrated efficacy and potential scalability of self-guided digital treatments for common mental health conditions, there is substantial variability in their uptake and engagement. This study explored the decision-making processes, influences and support needs of people taking up a self-guided digital treatment for anxiety and/or depression. METHODS: Australian-based adults (n = 20) were purposively sampled from a trial of self-guided digital mental health treatment. One-to-one, semistructured interviews were conducted, based on the Ottawa Decision-Support Framework. Interviews were transcribed verbatim and analysed thematically using framework methods. Baseline sociodemographic, clinical and decision-making characteristics were also collected. RESULTS: Analyses yielded four themes. Theme 1 captured participants' openness to try self-guided digital treatment, despite limited deliberation on potential downsides or alternative options. Theme 2 highlighted that immediacy and ease of access were major drivers of uptake, which participants contrasted with gaps in access and continuity of care in face-to-face services, especially rurally. Theme 3 centred on participants as the main agents in their decision-making, with family and health professional attitudes also reportedly influencing decision-making. Theme 4 revealed participants' primary motivations for deciding to take up treatment (e.g., the potential to increase insight and coping skills), while also acknowledging that pre-existing characteristics (e.g., health and digital literacy, insight) determined participants' personal suitability for self-guided digital treatment. CONCLUSION: Findings help to elucidate the decision-making influences and processes amongst people who started a self-guided treatment for depression and anxiety. Additional information and decision support resources appear warranted, which may also improve the accessibility of self-guided treatments. PUBLIC OR PATIENT CONTRIBUTION: Patients were interviewed about their views and experiences of decision-making about accessing and taking up treatment. As such, patient contribution to the research was as study participants.

Perceptions of client stories in internet-delivered cognitive behaviour therapy: A mixed-methods evaluation.

Internet-delivered Cognitive-Behavioural Therapy (ICBT) aims to support people with mental health concerns using online treatment materials. Client stories (either real or a composite based on many clients) are often used in ICBT to facilitate learning. However, these stories remain understudied in terms of how they are perceived by clients, as well as their relationship to ICBT engagement, satisfaction, and outcomes. Among a sample of 324 clients enrolled in transdiagnostic ICBT targeting symptoms of depression and anxiety, we examined client perceptions of stories through mixed-method qualitative (open-ended) and quantitative (closed-ended) data collection. Specifically, 234 (72.22 %) clients responded to questions about stories at 4 weeks and 221 (68.21 %) responded to questions at 8 weeks. Most clients who responded to questions endorsed reviewing at least some stories (79.06 % at 4 weeks, 71.95 % at 8 weeks). Moreover, they rated stories positively in terms of being relatable, making clients feel less alone, increasing knowledge, providing ideas for how to use skills, and motivating clients to use skills. These perceptions of stories remained stable over the course of treatment. Stories were perceived more positively among those with lower symptom severity at 8 weeks as well as those who were more satisfied with ICBT at 8 weeks. Story perceptions at 4 weeks were predictive of decreased post-treatment anxiety symptom severity but not depression while controlling for baseline scores, age, and education. 26.49 % of clients at 4 weeks who reviewed stories and 33.33 % at 8 weeks provided suggestions about how to improve stories. In a qualitative analysis, we found 5 categories of suggestions including increasing the variety of issues and relatability of stories, ensuring the stories are realistic, refining the formatting, and making the stories shorter. Overall, this study provides insights into how client stories could be improved to play a more significant role in future ICBT programs.

Cognitive behavioral therapies for depression and anxiety in people with chronic disease: A systematic review and meta-analysis.

OBJECTIVE: Anxiety and depression in chronic disease are common and burdensome co-morbidities. There has been growing interest in cognitive and behavioral therapies (CBTs) for anxiety and depression in chronic disease, however their efficacy has not been well-established. This study examined the efficacy of CBTs for depression and/or anxiety symptoms within chronic disease and explored the moderating role of clinical and methodological characteristics. METHODS: Following prospective registration, electronic databases were searched up to 2023 for randomized controlled trials (RCTs) examining CBTs for depression and/or anxiety in any adult chronic disease population. RESULTS: We included 56 RCTs. The overall effect of CBTs was g = 0.61 (95% CI, 0.49, 0.72) for depression and g = 0.56 (95% CI, 0.42, 0.70) for anxiety. A range of methodological features significantly moderated the effect sizes obtained, including type of control group and the outcome measure used. Risk of Bias ratings indicated some concerns regarding RCT conduct and reporting. CONCLUSIONS: CBTs lead to moderate improvements in both depression and anxiety symptoms among people with chronic disease. However, the efficacy of CBT should be interpreted considering certain study and sample characteristics. It is recommended that future studies make improvements to study methodology and reporting.

Examining the Utility of a Sleep Resource in Transdiagnostic Internet-Delivered Cognitive Behavior Therapy: An Observational Study.

Patients seeking transdiagnostic internet-delivered cognitive behavior therapy (T-ICBT) for anxiety or depression often have sleep difficulties. A brief resource that includes sleep psychoeducation and strategies for improving sleep (e.g., stimulus control and sleep restriction) may address comorbid insomnia without the need for an insomnia-specific ICBT course. This observational study explored patient use and feedback of a brief sleep resource available to all patients (n = 763) enrolled in an 8-week T-ICBT course. Overall, 30.1% of patients (n = 230) reviewed the resource and were older, more engaged with the ICBT course (i.e., more likely to complete the program, more logins, and greater number of days enrolled in the course) and had higher pretreatment insomnia symptoms than those who did not review the resource. Resource reviewers did not report larger improvements in symptoms of insomnia than non-reviewers, even among patients with clinical levels of insomnia, and average insomnia levels remained above the clinical cutoff at posttreatment. While patients were satisfied with the resource and it was beneficial to some patients, more research is needed to further explore how it may be integrated into T-ICBT and how therapists can encourage the use of the resource among patients who may benefit from the resource.

Understanding Client Difficulties in Transdiagnostic Internet-Delivered Cognitive Behaviour Therapy: A Qualitative Analysis of Homework Reflections.

Internet-delivered cognitive behaviour therapy (ICBT) is helpful for many clients, but less is known about the challenges clients face during ICBT, such as difficulties with skill practice, development, or maintenance. Understanding client difficulties can help therapists support clients with skill development and prevent treatment drop-out, but has not been systematically studied. This study included a conventional content analysis of clients' responses to a homework reflection question about difficulties with lessons and skills. Data was drawn from a previously published trial of 301 clients who were randomly assigned to receive homework reflection questions during ICBT. A decreasing number of clients responded to the question about skill difficulties with each lesson. Clients who answered the question about difficulties were more engaged with ICBT (i.e., more lessons completed, logins, days enrolled in ICBT, and messages sent to therapists). Clients shared skill-specific challenges (including initial challenges and more advanced challenges), generic challenges (content or skills being cognitively draining or emotionally draining, contextual challenges, forgetfulness, limited time, and lack of familiarity with the skill), or no challenges. Thought challenging (59.6%) and graded exposure (57.5%) were associated with the greatest number of skill-specific challenges. Findings can help therapists anticipate and address common client challenges during ICBT.

Insights into internet-delivered cognitive behavioural therapy for public safety personnel: Exploration of client experiences during and after treatment.

Canadian public safety personnel (PSP) experience high rates of mental health problems and barriers to receiving care. Internet-delivered cognitive behavioural therapy (ICBT) may help reduce barriers to care; however, there is no literature involving qualitative analyses of client feedback to describe PSP experiences with ICBT. Identifying these experiences is important because it can inform future use of ICBT with this group that has unique needs. The current study was designed to explore how clients (N = 82) experienced ICBT that had been tailored to meet their needs; specifically, the study assessed their perceptions of program impacts, what clients found helpful, and client suggestions for improvements. The ICBT course included five core lessons, client stories, and nine initial additional resources, as well as flexible frequencies (optional, once weekly, or twice weekly) and durations (8 to 16 weeks) of therapist support. A qualitative reliability thematic analysis was used to analyze client communications and feedback. Responses to a Treatment Satisfaction Questionnaire administered at eight weeks post-enrollment were available for 57 clients. Client emails with therapists were also examined among all clients, including an additional 25 clients who did not complete the Treatment Satisfaction Questionnaire. Themes identified in the qualitative analyses were related to: reported impacts and hindering events, helpful and challenging course skills and content, helpful aspects of the course, and areas for improvement. Clients who completed the Treatment Satisfaction Questionnaire and those who did not reported beneficial impacts from the program, with the most commonly endorsed themes being skill development and normalizing mental health issues. Hindering events were experienced by both groups and included timeline challenges, technology challenges, and negative effects. Comments from both groups suggested that clients had more success than challenges when practicing the skills. Thought challenging was the skill most frequently identified as helpful. Clients described many aspects of the program as helpful with the most frequently endorsed themes being the course format and content, the flexible nature of the course, access to additional materials and case stories, and therapist assistance. Clients also provided suggestions for improving the course (e.g., case stories, additional resources, timelines audio and videos). Overall, client communications suggest that ICBT is accepted and perceived as beneficial among PSP. These results informed rapid improvements to the ICBT program tailored for PSP and may inform others seeking to provide digital mental health services to PSP.

Disability and life satisfaction in neurological disorders: The role of depression and perceived cognitive difficulties.

BACKGROUND: This study assessed factors associated with disability and life satisfaction in a large cohort of 2246 Australian adults with neurological disorders who completed an online survey of mental health and wellbeing. It was hypothesised that depressive symptoms and perceived cognitive difficulties would be significantly associated with both outcomes, even after controlling for significant demographic/medical covariates (e.g., age, marital-status, employment, multi-morbidity, medication). Differences in profiles of four neurological subgroups (i.e., multiple sclerosis; n = 738, epilepsy; n = 672, Parkinson's disease; n = 263, and Acquired Bran Injury; n = 278) were explored. METHODS: Multiple hierarchical linear regressions were run using cross-sectional data. RESULTS: Depressive symptoms made a significant and large unique contribution to higher levels of disability (ß = 0.333, p < .001), and poorer life satisfaction (ß = -0.434, p < .001), in the overall sample and across all four neurological subgroups (ß = 0.349 to 0.513, p < .001) Greater perceived cognitive difficulties were associated with disability in the overall sample (ß = 0.318, p < .001) and across all neurological subgroups (ß = 0.231 to 0.354, p < .001), but only life satisfaction in epilepsy (ß = -0.107, p = 006). CONCLUSIONS: The findings underscore the importance of managing psychological/neuropsychiatric comorbidities in neurological disorders.

Guided internet-delivered cognitive-behaviour therapy for persons with spinal cord injury: a feasibility trial.

STUDY DESIGN: Observational pre-post study. OBJECTIVE: Guided internet-delivered CBT (ICBT) offers an alternative approach for mental health service delivery in the community for those with spinal cord injury (SCI). The feasibility and acceptability of guided ICBT programme is available for various chronic health conditions; however, the evidence related to SCI is limited. The primary aim of the current study was to examine feasibility and acceptability of a guided transdiagnostic ICBT programme for persons with SCI. SETTING: Community. METHODS: In this single-group pre-post study, persons with SCI (n = 20) living in the community were provided with a guided 8-week transdiagnostic ICBT programme for overall well-being. Study feasibility was examined by the following outcomes: patient recruitment, engagement, and attrition. Acceptability of the programme was evaluated post-treatment. Reductions in symptoms of depression and anxiety were assessed at baseline, post-intervention, and at 3-month follow-up. RESULTS: Approximately 60% of eligible participants were recruited. The study found high rates of programme completion (90%) and outcome data were obtained from 90% of participants. Improvement in symptoms of depression (and anxiety) were seen after treatment. Gains were maintained at 3-month follow-up. CONCLUSIONS: Guided transdiagnostic ICBT programme is a feasible and acceptable treatment option for those with psychological needs following SCI.

Self-guided internet-delivered cognitive behavior therapy (ICBT) for obsessive-compulsive symptoms: A randomized controlled trial.

Internet-delivered cognitive behavior therapy (ICBT) for obsessive-compulsive disorder (OCD) has been demonstrated to be efficacious across multiple clinical trials. However, most of these interventions include clinician support, and many individuals with OCD prefer to manage their own symptoms. Self-guided ICBT overcomes this problem, but to date the efficacy of self-guided interventions has only been studied in uncontrolled trials. The present study aims to examine the efficacy and acceptability of ICBT for OCD symptoms when delivered in a self-guided format using a randomized controlled trial design. In the present study, 190 participants were randomized to either a self-guided ICBT condition or a waitlist control group. 140 participants completed the baseline assessment, initiated treatment, and were included in the analyses. The between-group effect size at post-treatment was large on the self-report version of the Yale-Brown Obsessive-Compulsive Scale (d = 1.05; 95% CI 0.89-1.21). Twenty-seven percent of the ICBT condition met conservative criteria for clinically significant change at post-treatment, which increased to thirty-eight percent at three-month follow-up. Participants rated the program as highly acceptable. The results indicate that self-guided ICBT may be a viable treatment option for some individuals with OCD symptoms.

Patient perspectives of Internet-delivered cognitive behavior therapy for psychosocial issues post spinal cord injury.

PURPOSE: Many individuals with a spinal cord injury (SCI) report significant symptoms of depression and/or anxiety post-SCI; however, access to mental health services can be limited. The purpose of this study was to evaluate patient perspectives on the acceptability of an 8-week guided Internet-delivered cognitive behavior therapy (ICBT) course (Chronic Conditions Course) for people with SCI. In particular, we sought to understand patient perceptions of facilitators and barriers of engaging in ICBT and strengths and weaknesses of ICBT program content. METHOD: Semistructured interviews were conducted with 8 SCI patients after completion of the ICBT course. The interviews were audio-recorded, transcribed verbatim, and examined by means of thematic analysis by 2 coders. RESULTS: Eight participants (mean age = 53.2 years; males = 50%; paraplegia = 67.5%) were interviewed. Four major themes emerged when examining facilitators to completing the program: accessibility, flexibility, motivation, and guided support. Barriers to completing the program included course timeframe and physical health. Strengths of the course included effective skill development and mental health prioritization. Suggested changes to the course included improved breadth of case stories, development of extra resources, adjusting the course timeframe to account for the SCI, and more support from the guide. CONCLUSIONS: ICBT was overall highlighted as an acceptable method of receiving care for people with SCI. The study provides direction for improving delivery of ICBT to ensure this method of treatment meets the needs of individuals with SCI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Summary of Key Issues Raised in the Technology for Early Awareness of Addiction and Mental Illness (TEAAM-I) Meeting.

Technology provides an unparalleled opportunity to remove barriers to earlier identification and engagement in services for mental and addictive disorders by reaching people earlier in the course of illness and providing links to just-in-time, cost-effective interventions. Achieving this opportunity, however, requires stakeholders to challenge underlying assumptions about traditional pathways to mental health care. In this Open Forum, the authors highlight key issues discussed in the Technology for Early Awareness of Addiction and Mental Illness (TEAAM-I) meeting-held October 13-14, 2016, in New York City-that are related to three identified areas in which technology provides important and unique opportunities to advance early identification, increase service engagement, and decrease the duration of untreated mental and addictive disorders.

The Pain Course: Exploring the Feasibility of an Internet-delivered Pain Management Program When Offered by a Tertiary Pain Management Service.

BACKGROUND: This study examined the acceptability and preliminary outcomes of an internet-delivered pain management program, the Pain Course, when offered by a specialist pain management clinic in a large public hospital. METHODS: A single-group feasibility open-trial design was used and 39 patients participated in the program, which ran for 8 weeks. Participants were supported through the program with weekly contact from a Clinical Psychologist at the clinic. RESULTS: All participants provided data at posttreatment and >90% of participants completed all 5 lessons of the course. High levels of satisfaction were observed and relatively little clinician time (M=71.99 min/participant; SD=32.82 min) was required to support patients through the program. Preliminary evidence of clinical improvements in depression symptoms (avg. improvement=38%; Cohen d=0.74), but not disability levels or anxiety symptoms, was observed in the overall sample. However, evidence of improvements was observed across all the primary outcomes among patients who had clinical levels of difficulties with disability (n=20; avg. improvement=11%; Cohen d=0.64), depression (n=17; avg. improvement=35%; Cohen d=1.24) and anxiety (n=8; avg. improvement=29%; Cohen d=0.57). CONCLUSIONS: These findings highlight the potential value of internet-delivered programs when provided by specialist pain management clinics as a part of their services and the value of larger scale studies in this area.

A feasibility trial of an Internet-delivered and transdiagnostic cognitive behavioral therapy treatment program for anxiety, depression, and disability among adults with epilepsy.

OBJECTIVE: Anxiety and depression are highly prevalent in people with epilepsy (PWE) and contribute to increased disability. Unfortunately, there are numerous barriers (e.g., cost, distance, and stigma) and service gaps (e.g., lack of services and trained clinicians) that prevent many PWE from accessing traditional face-to-face psychological services. The aim of the present study was to examine the feasibility of a new transdiagnostic Internet-delivered cognitive behavioral therapy (iCBT) program, the Chronic Conditions Course, to simultaneously treat symptoms of anxiety, depression, and disability. METHODS: A single-group feasibility open trial was employed involving 27 adults with epilepsy. The program comprises five online lessons delivered over 8 weeks and is provided with weekly contact from a mental health professional via e-mail and telephone. RESULTS: High treatment completion rates and levels of satisfaction were reported. Evidence of significant improvements in our primary outcomes (within-group Cohen's d [d]; average [avg.] reductions) of anxiety (d ≥ 1.28; avg. reduction ≥ 54%), depression (d ≥ 1.24; avg. reduction ≥ 54%), epilepsy-specific depression (d ≥ 0.95; avg. reduction ≥ 35%), and disability (d ≥ 0.62; avg. reduction ≥ 33%) were observed at posttreatment, which were sustained at or further improved to 3-month follow-up. On our secondary outcomes there were significant improvements for life satisfaction (d ≥ 0.70; avg. improvement ≥ 26%) but not for perceived cognitive difficulties (d ≥ 0.48; avg. reduction ≥ 15%). Highlighting the potential of the approach, relatively little clinician time was required per participant (mean 80.62 min, standard deviation [SD] 54.78), and the trial involved a broad range of geographically dispersed patients. SIGNIFICANCE: The findings of the current study support the feasibility and potential of transdiagnostic Internet-delivered treatments for adults with epilepsy. Further large-scale controlled trials are warranted.

Examining internet-delivered cognitive behaviour therapy for patients with chronic kidney disease on haemodialysis: A feasibility open trial.

OBJECTIVE: Treating depression among patients with chronic kidney disease (CKD) is imperative because of its high prevalence and health-related costs. However, many patients with CKD experience significant barriers to effective face-to-face psychological treatments. Internet-delivered cognitive behaviour therapy (iCBT) may help overcome the treatment barriers. The aim of the present study was to explore the acceptability and preliminary efficacy of iCBT for depression and anxiety among patients with CKD on haemodialysis. METHODS: A single-group open trial design involving 22 patients on dialysis and an established iCBT treatment for anxiety and depression was employed. The primary outcomes were symptoms of depression, anxiety and general psychological distress. The secondary and tertiary outcomes were disability, quality of life, kidney disease-related loss and kidney disease burden. A generalised estimation equation modelling technique was employed. RESULTS: Clinically significant improvements (avg. % of improvement) were observed in the primary outcomes of depression (34%), anxiety (31%) and general distress (26%), which were maintained or further improved to 3-month follow-up. Improvements were also observed for quality of life (12%) and kidney disease-related loss (30%). However, no improvements in disability and kidney disease burden were found. High levels of acceptability were reported and relatively little clinician time (99.45min; SD=14.61) was needed to provide the treatment. CONCLUSION: The present results provide encouraging support for the potential of iCBT as an innovative way of increasing access to effective psychological treatment for CKD patients. These results provide much needed support for further research in this area. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN12613000103763.

The Pain Course: a randomised controlled trial of a clinician-guided Internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being.

The present study evaluated the efficacy of a clinician-guided Internet-delivered cognitive behaviour therapy (iCBT) program, the Pain Course, to reduce disability, anxiety, and depression associated with chronic pain. Sixty-three adults with chronic pain were randomised to either a Treatment Group or waitlist Control Group. Treatment consisted of 5 iCBT-based lessons, homework tasks, additional resources, weekly e-mail or telephone contact from a Clinical Psychologist, and automated e-mails. Twenty-nine of 31 Treatment Group participants completed the 5 lessons during the 8-week program, and posttreatment and 3-month follow-up data were collected from 30/31 and 29/31 participants, respectively. Treatment Group participants obtained significantly greater improvements than Control Group participants in levels of disability, anxiety, depression, and average pain levels at posttreatment. These improvements corresponded to small to large between-groups effect sizes (Cohen's d) at posttreatment for disability (d = .88), anxiety (d = .38), depression (d = .66), and average pain (d = .64), respectively. These outcomes were sustained at follow-up and participants rated the program as highly acceptable. Overall, the clinician spent a total mean time of 81.54 minutes (SD 30.91 minutes) contacting participants during the program. The results appear better than those reported in iCBT studies to date and provide support for the potential of clinician-guided iCBT in the treatment of disability, anxiety, and depression for people with chronic pain.