Race, Ethnicity, and Other Cultural Background Factors in Trials of Internet-Based Cognitive Behavioral Therapy for Depression: Systematic Review.

BACKGROUND: There is a growing interest in developing scalable interventions, including internet-based cognitive behavioral therapy (iCBT), to meet the increasing demand for mental health services. Given the growth in diversity worldwide, it is essential that the clinical trials of iCBT for depression include diverse samples or, at least, report information on the race, ethnicity, or other background indicators of their samples. Unfortunately, the field lacks data on how well diversity is currently reported and represented in the iCBT literature. OBJECTIVE: Thus, the main objective of this systematic review was to examine the overall reporting of racial and ethnic identities in published clinical trials of iCBT for depression. We also aimed to review the representation of specific racial and ethnic minoritized groups and the inclusion of alternative background indicators such as migration status or country of residence. METHODS: Studies were included if they were randomized controlled trials in which iCBT was compared to a waiting list, care-as-usual, active control, or another iCBT. The included papers also had to have a focus on acute treatment (eg, 4 weeks to 6 months) of depression, be delivered via the internet on a website or a smartphone app and use guided or unguided self-help. Studies were initially identified from the METAPSY database (n=59) and then extended to include papers up to 2022, with papers retrieved from Embase, PubMed, PsycINFO, and Cochrane (n=3). Risk of bias assessment suggested that reported studies had at least some risk of bias due to use of self-report outcome measures. RESULTS: A total of 62 iCBT randomized controlled trials representing 17,210 participants are summarized in this study. Out of those 62 papers, only 17 (27%) of the trials reported race, and only 12 (19%) reported ethnicity. Reporting outside of the United States was very poor, with the United States accounting for 15 (88%) out of 17 of studies that reported race and 9 (75%) out of 12 for ethnicity. Out of 3,623 participants whose race was reported in the systematic review, the racial category reported the most was White (n=2716, 74.9%), followed by Asian (n=209, 5.8%) and Black (n=274, 7.6%). Furthermore, only 25 (54%) out of the 46 papers conducted outside of the United States reported other background demographics. CONCLUSIONS: It is important to note that the underreporting observed in this study does not necessarily indicate an underrepresentation in the actual study population. However, these findings highlight the poor reporting of race and ethnicity in iCBT trials for depression found in the literature. This lack of diversity reporting may have significant implications for the scalability of these interventions.

Acceptability and Outcomes of Transdiagnostic Guided Self-help Bibliotherapy for Internalizing Disorder Symptoms in Adults: A Fully Remote Nationwide Open Trial.

Introduction: Doing What Matters in Times of Stress (DWM) is a five-module transdiagnostic guided self-help (GSH) intervention developed by the World Health Organization, originally in a group-based format. In a sample of individuals recruited from across the United States, we conducted an open trial to study the feasibility and acceptability of an adaptation of DWM in which guidance was provided individually and remotely via phone and videoconferencing. Methods: We assessed internalizing symptoms, psychological well-being, work and social functioning, usability of the intervention, and emotion regulation over the course of 6 weeks. Results: A total of 263 individuals completed our screening. Of those, 75.29% (n = 198) qualified for the intervention. We reached most participants who qualified (71.21%, n = 141) via phone to schedule a GSH session. Most of those scheduled attended a study session (84.4%, n = 119), and most of those who attended a session completed more than half the treatment (84.03%, n = 100). Retention rates were comparable to meta-analytic estimates of dropout rates in GSH. Participants showed improvement on internalizing symptoms, psychological well-being, work and social functioning, usability of the intervention, and emotion regulation. Conclusion: DWM is a freely available, seemingly efficacious transdiagnostic intervention for internalizing disorder symptoms. Supplementary Information: The online version contains supplementary material available at 10.1007/s10608-022-10338-5.

Willingness to Use Internet-Based Versus Bibliotherapy Interventions in a Representative US Sample: Cross-sectional Survey Study.

BACKGROUND: Self-help interventions have the potential to increase access to evidence-based mental health care. Self-help can be delivered via different formats, including print media or digital mental health interventions (DMHIs). However, we do not know which delivery format is more likely to result in higher engagement. OBJECTIVE: The aims of this study were to identify if there is a preference for engaging in print media versus DMHIs and whether there are individual differences in relative preferences. METHODS: Participants were 423 adults between the ages of 18 and 82 years (201/423, 47.5% female) recruited on Prolific as a nationally representative sample of the US population, including non-Hispanic White (293/423, 69.2%), non-Hispanic Black (52/423, 12%), Asian (31/423, 7%), Hispanic (25/423, 6%), and other individuals (22/423, 5%). We provided individuals with psychoeducation in different self-help formats and measured their willingness to use print media versus DMHIs. We also assessed participants' demographics, personality, and perception of each format's availability and helpfulness and used these to predict individual differences in the relative preferences. RESULTS: Participants reported being more willing to engage with print media than with DMHIs (B=0.41, SE 0.08; t422=4.91; P<.001; d=0.24, 95% CI 0.05-0.43). This preference appeared to be influenced by education level (B=0.22, SE 0.09; t413=2.41; P=.02; d=0.13, 95% CI -0.06 to 0.32), perceived helpfulness (B=0.78, SE 0.06; t411=13.66; P<.001; d=0.46, 95% CI 0.27-0.66), and perceived availability (B=0.20, SE 0.58; t411=3.25; P=.001; d=0.12, 95% CI 0.07-0.30) of the self-help format. CONCLUSIONS: This study suggests an overall preference for print media over DMHIs. Future work should investigate whether receiving mental health treatment via participants' preferred delivery format can lead to higher engagement.

Social Media Use, Physical Activity, and Internalizing Symptoms in Adolescence: Cross-sectional Analysis.

BACKGROUND: Most American adolescents have access to smartphones, and recent estimates suggest that they spend considerable time on social media compared with other physical and leisure activities. A large body of literature has established that social media use is related to poor mental health, but the complicated relationship between social media and symptoms of depression and anxiety in adolescents is yet to be fully understood. OBJECTIVE: We aim to investigate the relationship between social media use and depression and anxiety symptoms in adolescents by exploring physical activity as a mediator. METHODS: A Qualtrics survey manager recruited adult panel participants between February and March 2019, who indicated that they had adolescent children who spoke English. A total of 4592 adolescent-parent dyads completed the survey that took approximately 39 minutes. The survey entailed completing web-based questionnaires assessing various aspects of social media use, psychological symptoms, and psychosocial factors. The average age of the adolescent participants was 14.62 (SD 1.68; range 12-17) years, and the majority of the adolescent sample was male (2392/4592, 52.09%). RESULTS: Total social media use was associated with more depressive symptoms (multiple R2=0.12; F3,4480=207.1; P<.001), anxiety (multiple R2=0.09; F3,4477=145.6; P<.001), and loneliness (multiple R2=0.06; F3,4512=98.06; P<.001), controlling for age and gender. Physical activity was associated with decreased depression and anxiety symptoms after controlling for other extracurricular activities and social media use (multiple R2=0.24; F5,4290=266.0; P<.001). There were significant differences in symptoms based on gender: female adolescents reported higher rates of social media use and males reported higher rates of depression. Nonbinary and transgender adolescents had higher rates of depression, anxiety, and loneliness than the female and male adolescents in the sample. CONCLUSIONS: In a nationally representative sample of adolescents, more social media use was associated with more severe symptoms of depression, anxiety, and loneliness. Increased physical activity was associated with decreased depression and anxiety symptoms. Physical activity partially mediated the relationship between social media use and depression and anxiety. As this was a cross-sectional study, we cannot conclude that social media use causes internalizing symptoms or that physical activity leads to decreased internalizing symptoms-there may be additional confounding variables producing the relationships we observed. Physical activity may protect against the potentially harmful effect of social media on some adolescents. The effect sizes were small to medium, and the results should be interpreted with caution. Other limitations of this study include our reliance on self-reporting. Future work should examine social media use beyond how much time adolescents spend using social media and instead focus on the nature of social media activity.

Beyond the cognitive insight paradox: Self-reflectivity moderates the relationship between depressive symptoms and general psychological distress in psychosis.

BACKGROUND: People with psychosis experience significant emotional burden and distress associated with the symptomatic consequences of their mental disorder, thus difficulting their recovery. Several studies have found self-reflectivity, a dimension of cognitive insight, to be associated with effects which taken together may seem paradoxical, by predicting less psychotic symptom severity but more depression. To elucidate this issue, we examined the influence of psychotic symptoms, depressive symptoms, and self-reflectivity, on psychological distress. Further, we tested whether self-reflectivity moderated the relationship between depressive symptoms and psychological distress. METHODS: Seventy-six outpatients with psychotic-spectrum disorders were assessed using measures of psychotic symptoms, depressive symptoms, cognitive insight (i.e., self-reflectivity, self-certainty) and psychological distress. RESULTS: A regression model revealed that depressive, positive symptoms and the interaction between depressive symptoms and self-reflectivity had a significant effect on psychological distress. The moderation analysis showed that higher levels of self-reflectivity were related to less psychological distress associated with depressive mood. CONCLUSIONS: The role of self-reflectivity on depression and distress may be more complex than a direct effect. Interventions targeted to improve metacognition by enhancing self-reflectivity might be important for lowering the psychological distress associated with depressive symptoms in people with psychosis.