Kylie Bennett

Effectiveness of a Web-Based Cognitive-Behavioral Tool to Improve Mental Well-Being in the General Population: Randomized Controlled Trial

Background Interventions to promote mental well-being can bring benefits to the individual and to society. The Internet can facilitate the large-scale and low-cost delivery of individually targeted health promoting interventions. Objective To evaluate the effectiveness of a self-directed Internet-delivered cognitive-behavioral skills training tool in improving mental well-being in a population sample. Methods This was a randomized trial with a waiting-list control. Using advertisements on a national health portal and through its mailing list, we recruited 3070 participants aged 18 or over, resident in England, and willing to give their email address and access a fully automated Web-based intervention. The intervention (MoodGYM) consisted of 5 interactive modules that teach cognitive-behavioral principles. Participants in the intervention arm received weekly email reminders to access the intervention. The control group received access to the intervention after the trial was completed and received no specific intervention or email reminders. Outcomes were assessed by using self-completion questionnaires. The primary outcome was mental well-being measured with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes were Center for Epidemiologic Studies Depression scale (CES-D) depression scores, Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety scores, EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) quality of life scores, physical activity, and health service use. All outcomes were measured at baseline, and at 6- and 12-week follow-ups. Results A total of 1529 (49.80%) participants completed final follow-up at 12 weeks. Retention was 73.11% (1123/1536) in the control arm and 26.47% (406/1534) in the intervention arm. No relationship between baseline measures and withdrawal could be established. The analysis of WEMWBS mental well-being scores using a linear mixed model for repeated measures showed no difference between intervention and control group at baseline (difference –0.124 points, 95% CI –0.814 to 0.566), and significant improvements for the intervention group at 6 weeks (2.542 points, 95% CI 1.693-3.390) and at 12 weeks (2.876 points, 95% CI 1.933-3.819). The model showed a highly significant (P<.001) intervention by time interaction effect. There were also significant improvements in self-rated scores of depression and anxiety. Given the high level of attrition, a sensitivity analysis with imputed missing values was undertaken that also showed a significant positive effect of the intervention. Conclusions Participants allocated to the intervention arm had an average increase of approximately 3 points on the WEMWBS scale compared to no increase for participants in the control group. Three points on this scale is approximately one-third of a standard deviation. In a low-cost automated intervention designed to shift the population distribution of mental well-being, a small difference per individual could yield a major benefit in population terms. In common with other Web-based interventions, there were high rates of attrition. Further work is needed to improve acceptability, to evaluate against placebo effect, and to disaggregate the effect on mental well-being from the effect on depression and anxiety. Trial Registration International Standard Randomised Controlled Trial Number Register ISRCTN 48134476; http://www.controlled-trials.com/ISRCTN48134476 (Archived by WebCite® at http://www.webcitation.org/6DFgW2p3Q)

Predictors of Adherence by Adolescents to a Cognitive Behavior Therapy Website in School and Community-Based Settings

Background There have been no previous studies of the variables that predict adherence to online depression and anxiety intervention programs among adolescents. However, research of traditionally delivered intervention programs for a variety of health conditions in adolescence suggests that health knowledge, type and level of symptomatology, race, socioeconomic status, treatment setting, and support may predict adherence. Objective The aim was to compare adherence rates and identify the predictors of adherence to a cognitive behavior therapy website in two adolescent samples that were offered the program in different settings and under different conditions of support. Methods The first adolescent sample consisted of 1000 school students who completed the MoodGYM program in a classroom setting over five weeks as part of a randomized controlled trial. The second sample consisted of 7207 adolescents who accessed the MoodGYM program spontaneously and directly through the open access URL. All users completed a brief survey before the start of the program that measured background characteristics, depression history, symptoms of depression and anxiety, and dysfunctional thinking. Results Adolescents in the school-based sample completed significantly more online exercises (mean = 9.38, SD = 6.84) than adolescents in the open access community sample (mean = 3.10, SD = 3.85; t 1088.62 = −28.39, P < .001). A multiple linear regression revealed that school-based setting (P < .001) and female gender (P < .001) were predictive of greater adherence, as were living in a rural area (P < .001) and lower pre-test anxiety (P = .04) scores for the school-based sample and higher pre-test depression scores (P = .01) for the community sample. A history of depression (P = .33) and pre-test warpy thoughts scores (P = .35) were not predictive of adherence in the school-based or community sample. Conclusion Adherence is greater in monitored settings, and the predictors of adherence differ between settings. Understanding these differences may improve program effectiveness and efficiency.

Internet-Based Interventions to Promote Mental Health Help-Seeking in Elite Athletes: An Exploratory Randomized Controlled Trial

Background Mental disorders are more common in young adults than at any other life stage. Despite this, young people have low rates of seeking professional help for mental health problems. Young elite athletes have less positive attitudes toward seeking help than nonathletes and thus may be particularly unlikely to seek help. Interventions aimed at increasing help-seeking in young elite athletes are warranted. Objective To test the feasibility and efficacy of three Internet-based interventions designed to increase mental health help-seeking attitudes, intentions, and behavior in young elite athletes compared with a control condition. Methods We conducted a randomized controlled trial (RCT) of three brief fully automated Internet-based mental health help-seeking interventions with 59 young elite athletes recruited online in a closed trial in Australia. The interventions consisted of a mental health literacy and destigmatization condition, a feedback condition providing symptom levels, and a minimal content condition comprising a list of help-seeking resources, compared with a control condition (no intervention). We measured help-seeking attitudes, intentions and behavior using self-assessed surveys. Participation was open to elite athletes regardless of their mental health status or risk of mental illness. Results Of 120 athletes initially agreeing to participate, 59 (49%) submitted a preintervention or postintervention survey, or both, and were included in the present study. Adherence was satisfactory, with 48 (81%) participants visiting both weeks of assigned intervention material. None of the interventions yielded a significant increase in help-seeking attitudes, intentions, or behavior relative to control. However, at postintervention, there was a trend toward a greater increase in help-seeking behavior from formal sources for the mental health literacy/destigmatization condition compared with control (P = .06). This intervention was also associated with increased depression literacy (P = .003, P = .005) and anxiety literacy (P = .002, P = .001) relative to control at postintervention and 3-month follow-up, respectively, and a reduction in depression stigma relative to control at postintervention (P = .01, P = .12) and anxiety stigma at 3-month follow-up (P = .18, P = .02). The feedback and help-seeking list interventions did not improve depression or anxiety literacy or decrease stigmatizing attitudes to these conditions. However, the study findings should be treated with caution. Due to recruitment challenges, the achieved sample size fell significantly short of the target size and the study was underpowered. Accordingly, the results should be considered as providing preliminary pilot data only. Conclusions This is the first RCT of an Internet-based mental health help-seeking intervention for young elite athletes. The results suggest that brief mental health literacy and destigmatization improves knowledge and may decrease stigma but does not increase help-seeking. However, since the trial was underpowered, a larger trial is warranted. Trial Registration 2009/373 (www.clinicaltrials.gov ID: NCT00940732), cited at http://www.webcitation.org/5ymsRLy9r.

Internet-Delivered Interpersonal Psychotherapy Versus Internet-Delivered Cognitive Behavioral Therapy for Adults With Depressive Symptoms: Randomized Controlled Noninferiority Trial

Background Face-to-face cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are both effective treatments for depressive disorders, but access is limited. Online CBT interventions have demonstrated efficacy in decreasing depressive symptoms and can facilitate the dissemination of therapies among the public. However, the efficacy of Internet-delivered IPT is as yet unknown. Objective This study examines whether IPT is effective, noninferior to, and as feasible as CBT when delivered online to spontaneous visitors of an online therapy website. Methods An automated, 3-arm, fully self-guided, online noninferiority trial compared 2 new treatments (IPT: n=620; CBT: n=610) to an active control treatment (MoodGYM: n=613) over a 4-week period in the general population. Outcomes were assessed using online self-report questionnaires, the Center for Epidemiological Studies Depression scale (CES-D) and the Client Satisfaction Questionnaire (CSQ-8) completed immediately following treatment (posttest) and at 6-month follow-up. Results Completers analyses showed a significant reduction in depressive symptoms at posttest and follow-up for both CBT and IPT, and were noninferior to MoodGYM. Within-group effect sizes were medium to large for all groups. There were no differences in clinical significant change between the programs. Reliable change was shown at posttest and follow-up for all programs, with consistently higher rates for CBT. Participants allocated to IPT showed significantly lower treatment satisfaction compared to CBT and MoodGYM. There was a dropout rate of 1294/1843 (70%) at posttest, highest for MoodGYM. Intention-to-treat analyses confirmed these findings. Conclusions Despite a high dropout rate and lower satisfaction scores, this study suggests that Internet-delivered self-guided IPT is effective in reducing depressive symptoms, and may be noninferior to MoodGYM. The completion rates of IPT and CBT were higher than MoodGYM, indicating some progress in refining Internet-based self-help. Internet-delivered treatment options available for people suffering from depression now include IPT. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 69603913; http://www.controlled-trials.com/ISRCTN69603913 (Archived by WebCite at http://www.webcitation.org/6FjMhmE1o)

Technology-Based Interventions for Mental Health in Tertiary Students: Systematic Review

Background Mental disorders are responsible for a high level of disability burden in students attending university. However, many universities have limited resources available to support student mental health. Technology-based interventions may be highly relevant to university populations. Previous reviews have targeted substance use and eating disorders in tertiary students. However, the effectiveness of technology-based interventions for other mental disorders and related issues has not been reviewed. Objective To systematically review published randomized trials of technology-based interventions evaluated in a university setting for disorders other than substance use and eating disorders. Methods The PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials databases were searched using keywords, phrases, and MeSH terms. Retrieved abstracts (n=1618) were double screened and coded. Included studies met the following criteria: (1) the study was a randomized trial or a randomized controlled trial, (2) the sample was composed of students attending a tertiary institution, (3) the intervention was delivered by or accessed using a technological device or process, (4) the age range of the sample was between 18 and 25 years, and (5) the intervention was designed to improve, reduce, or change symptoms relating to a mental disorder. Results A total of 27 studies met inclusion criteria for the present review. Most of the studies (24/27, 89%) employed interventions targeting anxiety symptoms or disorders or stress, although almost one-third (7/24, 29%) targeted both depression and anxiety. There were a total of 51 technology-based interventions employed across the 27 studies. Overall, approximately half (24/51, 47%) were associated with at least 1 significant positive outcome compared with the control at postintervention. However, 29% (15/51) failed to find a significant effect. Effect sizes were calculated for the 18 of 51 interventions that provided sufficient data. Median effect size was 0.54 (range –0.07 to 3.04) for 8 interventions targeting depression and anxiety symptoms and 0.84 (range –0.07 to 2.66) for 10 interventions targeting anxiety symptoms and disorders. Internet-based technology (typically involving cognitive behavioral therapy) was the most commonly employed medium, being employed in 16 of 27 studies and approximately half of the 51 technology-based interventions (25/51, 49%). Distal and universal preventive interventions were the most common type of intervention. Some methodological problems were evident in the studies, with randomization methods either inadequate or inadequately described, few studies specifying a primary outcome, and most of the studies failing to undertake or report appropriate intent-to-treat analyses. Conclusions The findings of this review indicate that although technological interventions targeting certain mental health and related problems offer promise for students in university settings, more high quality trials that fully report randomization methods, outcome data, and data analysis methods are needed.

The Effectiveness of an Online Support Group for Members of the Community with Depression: A Randomised Controlled Trial

Background Internet support groups (ISGs) are popular, particularly among people with depression, but there is little high quality evidence concerning their effectiveness. Aim The study aimed to evaluate the efficacy of an ISG for reducing depressive symptoms among community members when used alone and in combination with an automated Internet-based psychotherapy training program. Method Volunteers with elevated psychological distress were identified using a community-based screening postal survey. Participants were randomised to one of four 12-week conditions: depression Internet Support Group (ISG), automated depression Internet Training Program (ITP), combination of the two (ITP+ISG), or a control website with delayed access to e-couch at 6 months. Assessments were conducted at baseline, post-intervention, 6 and 12 months. Results There was no change in depressive symptoms relative to control after 3 months of exposure to the ISG. However, both the ISG alone and the combined ISG+ITP group showed significantly greater reduction in depressive symptoms at 6 and 12 months follow-up than the control group. The ITP program was effective relative to control at post-intervention but not at 6 months. Conclusions ISGs for depression are promising and warrant further empirical investigation. Trial Registration Controlled-Trials.com ISRCTN65657330

Predictors and moderators of response to internet-delivered Interpersonal Psychotherapy and Cognitive Behavior Therapy for depression

BACKGROUND By identifying which predictors and moderators lead to beneficial outcomes, accurate selection of the best initial treatment will have significant benefits for depressed individuals. METHOD An automated, fully self-guided randomized controlled internet-delivered noninferiority trial was conducted comparing two new interventions (Interpersonal Psychotherapy [IPT; n=620] and Cognitive Behavioral Therapy [CBT; n=610]) to an active control intervention (MoodGYM; n=613) over a period of 4 weeks to spontaneous visitors of an internet-delivered therapy website (e-couch). A range of putative predictors and moderators (socio-demographic characteristics [age, gender, marital status, education level], clinical characteristics [depression/anxiety symptoms, disability, quality of life, medication use], skills [mastery and dysfunctional attitudes] and treatment preference) were assessed using internet-delivered self-report measures at baseline and immediately following treatment and at six months follow-up. Analyses were conducted using Mixed Model Repeated Measures (MMRM). RESULTS Female gender, lower mastery and lower dysfunctional attitudes predicted better outcome at post-test and/or follow-up regardless of intervention. No overall differential effects for condition on depression as a function of outcome were found. However, based on time-specific estimates, a significant interaction effect of age was found. For younger people, internet-delivered IPT may be the preferred treatment choice, whereas older participants derive more benefits from internet-delivered CBT programs. LIMITATIONS Although the sample of participants was large, power to detect moderator effects was still lacking. CONCLUSIONS Different e-mental health programs may be more beneficial for specific age groups. The findings raise important possibilities for increasing depression treatment effectiveness and improving clinical practice guidelines for depression treatment of different age groups.

Security Considerations for E-Mental Health Interventions

Security considerations are an often overlooked and underfunded aspect of the development, delivery, and evaluation of e-mental health interventions although they are crucial to the overall success of any eHealth project. The credibility and reliability of eHealth scientific research and the service delivery of eHealth interventions rely on a high standard of data security. This paper describes some of the key methodological, technical, and procedural issues that need to be considered to ensure that eHealth research and intervention delivery meet adequate security standards. The paper concludes by summarizing broad strategies for addressing the major security risks associated with eHealth interventions. These include involving information technology (IT) developers in all stages of the intervention process including its development, evaluation, and ongoing delivery; establishing a wide-ranging discourse about relevant security issues; and familiarizing researchers and providers with the security measures that must be instituted in order to protect the integrity of eHealth interventions.

The GoodNight study—online CBT for insomnia for the indicated prevention of depression: study protocol for a randomised controlled trial

BackgroundCognitive Behaviour Therapy for Insomnia (CBT-I) delivered through the Internet is effective as a treatment in reducing insomnia in individuals seeking help for insomnia. CBT-I also lowers levels of depression in this group. However, it is not known if targeting insomnia using CBT-I will lower depressive symptoms, and thus reduce the risk of major depressive episode onset, in those specifically at risk for depression. Therefore, this study aims to examine whether Internet delivery of fully automated self-help CBT-I designed to reduce insomnia will prevent depression.Method/designA sample of 1,600 community-dwelling adults (aged 18–64), who screen positive for both subclinical levels of depressive symptoms and insomnia, will be recruited via various media and randomised to either a 9-week online insomnia treatment programme, Sleep Healthy Using The internet (SHUTi), or an online attention-matched control group (HealthWatch). The primary outcome variable will be depression symptom levels at the 6-month post-intervention on the Patient Heath Questionnaire-9 (PHQ-9). A secondary outcome will be onset of major depressive episodes assessed at the 6-month post-intervention using ‘current’ and ‘time from intervention’ criteria from the Mini International Neuropsychiatric Interview.DiscussionThis trial is the first randomised controlled trial of an Internet-based insomnia intervention as an indicated preventative programme for depression. If effective, online provision of a depression prevention programme will facilitate dissemination.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), Registration number: ACTRN12611000121965.

Health e-cards as a means of encouraging help seeking for depression among young adults: randomized controlled trial.

Background There is a need to identify interventions that increase help seeking for depression among young adults. Objective The aim was to evaluate a brief depression information intervention employing health e-cards (personalized emails containing links to health information presented on a Web page). Methods A randomized controlled trial was carried out with 348 19- to 24-year-olds drawn from the community. Participants were randomized to receive one of three conditions, all of which delivered a short series of health e-cards. Two active conditions involved the delivery of depression information designed to increase help-seeking behavior and intentions and to improve beliefs and knowledge associated with help seeking. A control arm delivered information about general health issues unrelated to depression. The primary outcome was help-seeking behavior. Secondary outcomes were help-seeking intentions; beliefs about the efficacy of depression treatments and help sources; ability to recognize depression; knowledge of the help-seeking process; and depressive symptoms. The study’s primary focus was outcomes relating to formal help seeking (consultation with a general practitioner or mental health professional) but also targeted behaviors, intentions, and beliefs relating to informal help seeking. Results Relative to the control condition, depression health e-cards were not associated with an increase in formal help-seeking behavior, nor were they associated with improved beliefs about depression treatments; ability to recognize depression; knowledge of the help-seeking process; or depressive symptoms. Depression e-cards were associated with improved beliefs about the overall efficacy of formal help sources (z = 2.4, P = .02). At post-intervention, participants in all conditions, relative to pre-intervention, were more likely to have higher intentions of seeking help for depression from a formal help source (t 641 = 5.8, P < .001) and were more likely to rate interpersonal psychotherapy as being helpful (z = 2.0, P = .047). Depression e-cards were not associated with any significant changes in informal help-seeking behavior, intentions, or beliefs. Conclusions The study found no evidence that providing depression information in the form of brief e-cards encourages help seeking for depression among young adults. Involvement in the study may have been associated with increased help-seeking intentions among participants in all conditions, suggesting that mechanisms other than depression information may increase help seeking. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN98406912; http://www.controlled-trials.com/ISRCTN98406912/ISRCTN98406912 (Archived by WebCite at http://www.webcitation.org/5k221KiMi)