Long-Term Effects of an Internet-Based Treatment for Posttraumatic Stress

Advances in communication technology offer additional strategies for providing psychological treatment. Previous trials of Internet-based treatment approaches reported significant reductions in posttraumatic stress and related symptoms in response to Internet-based treatments relative to control groups. However, empirical data on the long-term effects of those approaches are sparse. In order to evaluate the long-term effect of an Internet-based intervention, the authors conducted an 18-month follow-up of an Internet-based cognitive behavioural therapy for posttraumatic stress. Severity of posttraumatic stress symptoms was the primary outcome. Additional measures were depression, anxiety, mental and physical health, and health care utilization during the follow-up period. Treatment group participants (n ¼ 34) were assessed 1.5 years after completing treatment. Results indicated that reductions in symptoms of posttraumatic stress symptoms, depression, and anxiety found at posttreatment were sustained during the 18-month follow-up period. Preliminary evidence on long-term effects of Internet-based health care as shown in this study is promising. However, research with larger and clinically more diverse samples is needed to fully assess the clinical impact and potential of Internet-based health care provision. Key words: online therapy; Internet; randomized controlled trial; long-term effects; cognitive behavioural treatment; PTS

Research into evidence-based psychological interventions needs a stronger focus on replicability

Background:It is a precondition for evidence-based practice that research is replicable in a wide variety of clinical settings. Current standards for identifying evidence-based psychological interventions and making recommendations for clinical practice in clinical guidelines include criteria that are relevant for replicability, but a better understanding as well refined definitions of replicability are needed enabling empirical research on this topic. Recent advances on this issue were made in the wider field of psychology and in other disciplines, which offers the opportunity to define and potentially increase replicability also in research on psychological interventions. Method: This article proposes a research strategy for assessing, understanding, and improving replicability in research on psychological interventions. Results/Conclusion: First, we establish a replication taxonomy ranging from direct to conceptual replication adapted to the field of research on clinical interventions, propose study characteristics that increase the trustworthiness of results, and define statistical criteria for successful replication with respect to the quantitative outcomes of the original and replication studies. Second, we propose how to establish such standards for future research, i.e., in order to design future replication studies for psychological interventions as well as to apply them when investigating which factors are causing the (non-)replicability of findings in the current literature

With a Little Help from my Friends: Acculturation and Mental Health in Arabic-speaking Refugee Youth Living with their Families

Introduction: Refugee youth are often faced with the compounding challenges of heightened exposure to traumatic events and acculturating to a new country during a developmental period when their sense of self is still forming. This study investigated whether refugee youth’s acculturation orientation (separation, integration, marginalization, and assimilation) is associated with depressive and posttraumatic stress symptoms and aimed to identify additional indicators of acculturation that may contribute to mental health. Methods: A total of 101 Arabic-speaking refugee youths (aged 14–20 years), who were living with their families and attending school in Germany, took part in the study. They answered questions concerning traumatic exposure and posttraumatic stress symptoms, depressive symptoms, and several indicators of acculturation, including cultural orientation, positive and negative intra- and intergroup contact, language skills and friendship networks. All participants were categorized into one of four acculturation orientations using median splits. Results: Kruskal–Wallis rank sum tests revealed that acculturation orientation was not significantly associated with depressive symptoms [χ2 (3, 97) = 0.519, p = 0.915] or posttraumatic stress symptoms [χ2 (3, 97) = 0.263, p = 0.967]. Regression analysis revealed that German language skills were significantly associated with lower scores of depressive symptoms (p = 0.016) and number of friends in Germany was significantly associated with lower scores of depressive (p = 0.006) and posttraumatic stress symptoms (p = 0.002), respectively. Discussion: Policies that provide refugee youth with access to language classes and social activities with peers do not only enable them to actively participate in a new society but may also have a positive effect on their mental health

A Latent Class Analysis on Symptoms of Prolonged Grief, Post-Traumatic Stress, and Depression Following the Loss of a Loved One

Background: The loss of a significant other can lead to variety of responses, including prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. The aim of this study was to replicate and extend previous research that indicated that three subgroups of bereaved individuals can be distinguished based one similar post-loss symptom profiles using latent class analysis (LCA). The second aim was to examine whether sociodemographic and loss-related characteristics as well as the extent of meaning making were related to classes with more pervasive psychopathology. Methods: Telephone-based interviews with 433 Dutch and German speaking persons who had lost a significant other at last 6 months earlier were conducted. Self-rated PGD, PTSD, and depression symptoms were assessed. LCA was conducted and correlates of class-membership were examined using the 3step approach. Results: The LCA resulted in three distinct classes: a no symptoms class (47%), a moderate PGD, low depression/PTSD class (32%), and a high PGD, moderate depression/PTSD class (21%). A multivariate analysis indicated that female gender, a shorter time since loss, an unexpected loss and less meaning made to a loss were significantly associated with membership to the moderate PGD, low depression/PTSD and high PGD, moderate depression/PTSD class compared to membership to the no symptom class. Losing a child or spouse, a shorter time since loss, and having made less meaning to the loss further distinguished between the high PGD, moderate depression/PTSD symptom class and the moderate PGD, low depression/PTSD class. Discussion: We found that the majority of individuals coped well in response to their loss since the no symptom class was the largest class. Post-loss symptoms could be categorized into classes marked by different intensity of symptoms, rather than qualitatively different symptom patterns. The findings indicate that perceiving the loss as more unexpected, finding less meaning in the loss, and loss-related factors, such as the recentness of a loss and the loss of a partner or child, were related to class membership more consistently than sociodemographic factors

Development of a Short and ICD-11 Compatible Measure for DSM-5 Maladaptive Personality Traits Using Ant Colony Optimization Algorithms

While Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM-5) Section III and ICD-11 (International Classification of Diseases 11th–Revision) both allow for dimensional assessment of personality pathology, the models differ in the definition of maladaptive traits. In this study, we pursued the goal of developing a short and reliable assessment for maladaptive traits, which is compatible with both models, using the item pool of the Personality Inventory for DSM-5 (PID-5). To this aim, we applied ant colony optimization algorithms in English- and German-speaking samples comprising a total N of 2,927. This procedure yielded a 34-item measure with a hierarchical latent structure including six maladaptive trait domains and 17 trait facets, the “Personality Inventory for DSM-5, Brief Form Plus” (PID5BF+). While latent structure, reliability, and criterion validity were ascertained in the original and in two separate validation samples (n = 849, n = 493) and the measure was able to discriminate personality disorders from other diagnoses in a clinical subsample, results suggest further modifications for capturing ICD-11 Anankastia

Internet-based treatment for PTSD reduces distress and facilitates the development of a strong therapeutic alliance: a randomized controlled clinical trial

BACKGROUND: The present study was designed to evaluate the efficacy of an internet-based therapy (Interapy) for Posttraumatic Stress Disorder (PTSD) in a German speaking population. Also, the quality of the online therapeutic relationship, its development and its relevance as potential moderator of the treatment effects was investigated. METHOD: Ninety-six patients with posttraumatic stress reactions were allocated at random to ten sessions of Internet-based cognitive behavioural therapy (CBT) conducted over a 5-week period or a waiting list control group. Severity of PTSD was the primary outcome. Secondary outcome variables were depression, anxiety, dissociation and physical health. Follow-up assessments were conducted at the end of treatment and 3 months after treatment. RESULTS: From baseline to post-treatment assessment, PTSD severity and other psychopathological symptoms were significantly improved for the treatment group (intent-to-treat group x time interaction effect size d = 1.40). Additionally, patients of the treatment condition showed significantly greater reduction of co-morbid depression and anxiety as compared to the waiting list condition. These effects were sustained during the 3-months follow-up period. High ratings of the therapeutic alliance and low drop-out rates indicated that a positive and stable therapeutic relationship could be established online. Significant improvement of the online working alliance in the course of treatment and a substantial correlation between the quality of the online relationship at the end of treatment and treatment outcome emerged. CONCLUSION: Interapy proved to be a viable treatment alternative for PTSD with large effect sizes and sustained treatment effects. A stable and positive online therapeutic relationship can be established through the Internet which improved during the treatment process. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN012606000401550

Guided digital health intervention for depression in Lebanon: randomised trial

<jats:sec><jats:title>Background</jats:title><jats:p>Most people with mental disorders in communities exposed to adversity in low-income and middle-income countries (LMICs) do not receive effective care. Digital mental health interventions are scalable when digital access is adequate, and can be safely delivered during the COVID-19 pandemic.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To examine the effects of a new WHO-guided digital mental health intervention, Step-by-Step, supported by a non-specialist helper in Lebanon, in the context of concurring economic, humanitarian and political crises, a large industrial disaster and the COVID-19 pandemic.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We conducted a single-blind, two-arm pragmatic randomised trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among people suffering from depression and impaired functioning. Primary outcomes were depression (Patient Health Questionnaire 9 (PHQ-9)) and impaired functioning (WHO Disability Assessment Schedule-12 (WHODAS)) at post-treatment.</jats:p></jats:sec><jats:sec><jats:title>Findings</jats:title><jats:p>680 people with depression (PHQ-9>10) and impaired functioning (WHODAS>16) were randomised to Step-by-Step or ECAU. Intention-to-treat analyses showed effects on depression (standardised mean differences, SMD: 0.71; 95% CI: 0.45 to 0.97), impaired functioning (SMD: 0.43; 95% CI: 0.21 to 0.65), post-traumatic stress (SMD: 0.53; 95% CI: 0.27 to 0.79), anxiety (SMD: 0.74; 95% CI: 0.49 to 0.99), subjective well-being (SMD: 0.37; 95% CI: 0.12 to 0.62) and self-identified personal problems (SMD: 0.56; 95% CI 0.29 to 0.83). Significant effects on all outcomes were retained at 3-month follow-up.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Guided digital mental health interventions can be effective in the treatment of depression in communities exposed to adversities in LMICs, although some uncertainty remains because of high attrition.</jats:p></jats:sec><jats:sec><jats:title>Clinical implications</jats:title><jats:p>Guided digital mental health interventions should be considered for implementation in LMICs.</jats:p></jats:sec><jats:sec><jats:title>Trial registration number</jats:title><jats:p>ClinicalTrials.gov <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="clintrialgov" xlink:href="NCT03720769">NCT03720769</jats:ext-link>.</jats:p></jats:sec&gt

Effectiveness of a peer-refugee delivered psychological intervention to reduce psychological distress among adult Syrian refugees in the Netherlands: study protocol

Background: Syrian refugees face multiple hardships and adversities which put them at risk for the development of mental health problems. However, access to adequate mental health care in host countries is limited. The WHO has developed Problem Management Plus (PM+), a brief, scalable psychological intervention, delivered by non-specialist helpers, that addresses common mental disorders in people affected by adversity. This study is part of the STRENGTHS project, that aims to evaluate peer-refugee delivered psychological interventions for Syrian refugees in Europe and the Middle East. Objective: To evaluate the effectiveness and cost-effectiveness of the peer-refugee delivered PM+ intervention among Syrian refugees with elevated levels of psychological distress in the Netherlands. Methods: PM+ will be tested in a randomized controlled trial (RCT) among Arabic-speaking Syrian refugees in the Netherlands aged 18 years and above with self-reported psychological distress (Kessler Psychological Distress Scale; K10 >15) and impaired daily functioning (WHO Disability Assessment Schedule; WHODAS 2.0 >16). Participants (N = 380) will be randomized into care as usual with PM+ (CAU/PM+, n = 190) or CAU only (CAU, n = 190). Baseline, 1-week post-intervention, and 3-month and 12-month follow-up assessments will be conducted. Primary outcomes are symptoms of depression and anxiety. Secondary outcomes are functional impairment, posttraumatic stress disorder symptoms, self-identified problems, anger, health and productivity costs, and hair cortisol concentrations. A process evaluation will be carried out to evaluate treatment dose, protocol fidelity and stakeholder views on barriers and facilitators to implementing PM+. Results and Conclusions: PM+ has proved effectiveness in other populations and settings. After positive evaluation, the adapted manual and training materials for individual PM+ will be made available through the WHO to encourage further replication and scaling up. Trial registration: Trial registration Dutch Trial Registry, NL7552, registered prospectively on March 1, 2019. Medical Ethics Review Committee VU Medical Center Protocol ID 2017.320, 7 September 2017

The working alliance in a randomized controlled trial comparing online with face-to-face cognitive-behavioral therapy for depression

Background: Although numerous efficacy studies in recent years have found internet-based interventions for depression to be effective, there has been scant consideration of therapeutic process factors in the online setting. In face-to face therapy, the quality of the working alliance explains variance in treatment outcome. However, little is yet known about the impact of the working alliance in internet-based interventions, particularly as compared with face-to-face therapy. Methods: This study explored the working alliance between client and therapist in the middle and at the end of a cognitive-behavioral intervention for depression. The participants were randomized to an internet-based treatment group (n = 25) or face-to-face group (n = 28). Both groups received the same cognitive behavioral therapy over an 8-week timeframe. Participants completed the Beck Depression Inventory (BDI) post-treatment and the Working Alliance Inventory at mid- and post- treatment. Therapists completed the therapist version of the Working Alliance Inventory at post-treatment. Results: With the exception of therapists' ratings of the tasks subscale, which were significantly higher in the online group, the two groups' ratings of the working alliance did not differ significantly. Further, significant correlations were found between clients' ratings of the working alliance and therapy outcome at post-treatment in the online group and at both mid- and post-treatment in the face-to-face group. Correlation analysis revealed that the working alliance ratings did not significantly predict the BDI residual gain score in either group. Conclusions: Contrary to what might have been expected, the working alliance in the online group was comparable to that in the face-to-face group. However, the results showed no significant relations between the BDI residual gain score and the working alliance ratings in either group

Peer-provided psychological intervention for Syrian refugees: results of a randomised controlled trial on the effectiveness of Problem Management Plus

Background The mental health burden among refugees in high-income countries (HICs) is high, whereas access to mental healthcare can be limited. Objective To examine the effectiveness of a peer-provided psychological intervention (Problem Management Plus; PM+) in reducing symptoms of common mental disorders (CMDs) among Syrian refugees in the Netherlands. Methods We conducted a single-blind, randomised controlled trial among adult Syrian refugees recruited in March 2019–December 2021 (No. NTR7552). Individuals with psychological distress (Kessler Psychological Distress Scale (K10) >15) and functional impairment (WHO Disability Assessment Schedule (WHODAS 2.0) >16) were allocated to PM+ in addition to care as usual (PM+/CAU) or CAU only. Participants were reassessed at 1-week and 3-month follow-up. Primary outcome was depression/anxiety combined (Hopkins Symptom Checklist; HSCL-25) at 3-month follow-up. Secondary outcomes included depression (HSCL-25), anxiety (HSCL-25), post-traumatic stress disorder (PTSD) symptoms (PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; PCL-5), impairment (WHODAS 2.0) and self-identified problems (PSYCHLOPS; Psychological Outcomes Profiles). Primary analysis was intention-to-treat. Findings Participants (n=206; mean age=37 years, 62% men) were randomised into PM+/CAU (n=103) or CAU (n=103). At 3-month follow-up, PM+/CAU had greater reductions on depression/anxiety relative to CAU (mean difference −0.25; 95% CI −0.385 to −0.122; p=0.0001, Cohen’s d=0.41). PM+/CAU also showed greater reductions on depression (p=0.0002, Cohen’s d=0.42), anxiety (p=0.001, Cohen’s d=0.27), PTSD symptoms (p=0.0005, Cohen’s d=0.39) and self-identified problems (p=0.03, Cohen’s d=0.26), but not on impairment (p=0.084, Cohen’s d=0.21). Conclusions PM+ effectively reduces symptoms of CMDs among Syrian refugees. A strength was high retention at follow-up. Generalisability is limited by predominantly including refugees with a resident permit. Clinical implications Peer-provided psychological interventions should be considered for scale-up in HICs